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THE JOURNAL 

OF 

MENTAL SCIENCE 


EDITORS: 

Henry Rayner, H.D. A. R. Urquhart, M.D. 

Conolly Norman, F.R.C.P.I. 


VOL. XLV. 



LONDON: 

J. & A. CHU RCH I LL, 

7, GREAT MARLBOROUGH STREET. 


MDCCCXCIX. 


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\ 



“In adopting our title of the Journal of Mental Science, published by authority 
of the Medico-Psychological Association, we profess that we cultivate in our pages 
mental science of a particular kind, namely, such mental science as appertains 
tQ rqedical men who are -engaged in the treatment of the insane. But it has 
been' objected that the term mental science \s inapplicable, And that the term 
mental physiology, or mental pathology, or psychology, or psychiatry (a term 
much affected by our German brethren), would have been more correct and ap¬ 
propriate ; and that, moreover, we do not deal in mental science, which is pro¬ 
perly the sphere of the aspiring metaphysical intellect. If mental science is 
strictly synonymous with metaphysics, these objections are certainly valid; for 
although we do not eschew metaphysical discussion, the aim of this Journal is 
certainly bent upon more attainable objects than the pursuit of those recondite 
inquiries which have occupied the most ambitious intellects from the time of 
Plato to the present, with so much labour and so little result. But while we 
admit that metaphysics may be called one department of mental science, we main¬ 
tain that mental physiology and mental pathology are also mental science under 
a different aspect. While metaphysics may be called speculative mental science, 
mental physiology and pathology, with their vast range of inquiry into insanity, 
education, crime, and all things which tend to preserve mental health, or to pro¬ 
duce mental disease, are not less questions of mental science in its practical, that 
is in its sociological point of view. If it were not unjust to high mathematics 
to compare it in any way with abstruse metaphysics, it would illustrate our 
meaning to say that our practical mental science would fairly bear the same rela¬ 
tion to the mental science of the metaphysicians as applied mathematics bears to 
the pure science. In both instances the aim of the pure science is the attainment 
of abstract truth ; its utility, however, frequently going no further than to serve 
as a gymnasium for the intellect. In both instances the mixed science aims at, 
and, to a certain extent, attains immediate practical results of the greatest utility 
to the welfare 6f'.Mankind; we therefore maintain that our Journal is not in¬ 
aptly called thq^ypMrmi/ of Mental Science, although the science may only at- 
terftpt*to deal wixh'SQciological and medical inquiries, relating either to the pre¬ 
servation of the'hearth of the mind or to the amelioration or cure of its diseases ; 
amTirthouglr noV.$6kring to the height of abstruse metaphysics, we only aim at 
such’ metaphysical*jcnowledge as may be available to our purposes, as the mecha¬ 
nician uses.'the-Tforkiularies of mathematics. This is our view of the kind of 
mental science -which physicians engaged in the grave responsibility of caring 
for ynje mental health of their fellow-men may, in all modesty, pretend to cultivate ; 
aftd^ White*w£ cSmnot doubt that all additions to our certain knowledge in the 
spgpulatMCe Hepa'^tn^ent of the science will be great gain, the necessities of duty 
and w of d$Pg£ r ever compel us to pursue that knowledge which is to be 

ofrtined*.in.|he\practical departments of science with the earnestness of real 
wi»rVmerr.». The«oajftain of a ship would be none the worse for being well acquainted 
w3tff*fhe‘higher branches of astronomical science, but it is the practical part of 
that, 3 pience as ft*.Inapplicable to navigation which he is compelled to study.” — 
&>y. C. Buckniti; •] M.D ., F.R.S. 


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THE 

JOURNAL OF MENTAL SCIENCE 


[.Published by Authority of the Medico-Psychological Association 
of Great Britain and Ireland ’] 

No. 188 [ NE N w 0 R f 5 R i“] JANUARY, 1899. Vol. XLV. 


Part I.—Original Articles. 


The Improvable Imbecile : his Training and Future . By 
A. R. Douglas, Deputy Medical Officer, H.M. Prison, 
Portland ; late Deputy Medical Superintendent, Royal 
Albert Asylum, Lancaster. 


The cause of the Imbecile has for some time past been a plea 
which has never failed to elicit the practical sympathy of the 
public ; yet much remains to be done before we have fulfilled our 
obligation to those who are not lunatics, and are capable, under 
suitable conditions, of being made self-supporting members of the 
community. As in this paper I intend to deal chiefly with the 
future of the improvable imbecile, I think that in the first place 
the statement that such an individual after training is indepen¬ 
dently capable of earning his own livelihood is as absurd as it 
is impossible. I shall presently endeavour to show that without 
supervision little or nothing can be expected from an imbecile, 
however highly trained and educated he may be ; his whole dis¬ 
position and temperament away from control completely negatives 
the supposition, and actual cases have proved that, unless under 
sympathetic and intelligent guidance, the life of the imbecile as 
far as usefulness is concerned is not only a blank, but that the 
individual himself is a burden, and in some instances a nuisance 
to society and his friends. Secondly, there can be no doubt 
that much of the careful and patient instruction bestowed upon 
such cases at the educational establishments is wasted, for the 
simple reason that at the expiration of their term there many 
improved imbeciles gravitate to conditions totally unsuitable for 




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2 THE IMPROVABLE IMBECILE, [Jan., 

them, and under which it is almost impossible to expect that 
the training which they have received will, so to speak, have a 
fair chance. On completion of their term of training it may 
be that in some cases the parents are dead, and there are no 
relations or guardians to look after them ; for a large number 
there is nothing but the workhouse. Again, their imbecile 
temperament causes others, perhaps in a moment of pique, to 
abandon the work which has been obtained for them possibly 
only by a vast amount of trouble, and they thus become a 
burden to their relatives. A third section are, away from 
supervision, incurably vicious, and many in the course of their 
career become gaol-birds and convicts. The imbecile is one 
who is totally, or in part, bereft of the faculties necessary to 
enable him to take a successful part in the battle of life, and I 
think that it may be safely assumed that, in the whirl of this 
nineteenth century, with its attributes of high pressure and 
overcrowding in every direction, the imbecile can of himself 
secure no place. His appearance, his mental and often 
physical deficiencies, are all dead against him, and his unstable 
equilibrium, manifested in uncertainty of temper and morals, 
renders him in many case$ quite unfit to be trusted away from 
proper care and supervision. In fact, it is unjust and unfair to 
forget this by exposing these individuals to risks by trusting 
them too far. 

With respect to the training of imbeciles, much admirable 
work is done at the great educational establishments at 
Lancaster, Earlswood, Colchester, and Exeter, the first named 
under the able superintendence of Mr. James Diggens. Here 
the results of training are as hopeful as could be expected when 
one considers the material which is dealt with, and which at 
first is often terribly lacking in promise for the future. It is, 
however, in the industrial departments that one really sees 
what improvable imbeciles are capable of learning, and what 
really excellent tradesmen many of them have become under 
the intelligent supervision and control of instructors, who are, 
as far as possible, chosen because they possess the requisite 
qualifications of temper and disposition calculated to gain con¬ 
fidence, which is vitally necessary to manage lads who are often 
wayward in temper, and prone, from their very infirmity, to 
idleness and vice. 

All who are familiar with imbeciles are aware of those cases 


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1899] 


BY A. R. DOUGLAS. 


3 


showing remarkable talents, one of which I shall now describe. 
Here is a lad of twenty years of age : he can read and write well, 
and is particularly clever at arithmetic ; but when we narrowly 
observe the boy we find that he suffers from severe athetosis, is 
quite unable to walk, even with assistance ; one arm is practi¬ 
cally useless, and the expression of his features is contorted con¬ 
stantly into horrible grimaces through muscular twitchings. We 
find that he has a violent temper, is very malicious, a confirmed 
masturbator and liar. Now here is a case where sufficient 
education has been imparted to enable him to hold a humble 
post, but he is so terribly handicapped physically and morally 
that he is totally debarred from earning his livelihood inde¬ 
pendently. I adduce another example of this very constant 
feature in these cases, this unstable equilibrium in varying degrees 
of intensity. The instance I have in mind is a very different 
one from the case just cited ; this is a youth with but little 
of the imbecile in his appearance : smart, bright, and intelli¬ 
gent-looking, he can read, write, and count, and is employed as 
messenger in an important department of the institution. This 
youth has times out of number been trusted with money, and, 
as far as that is concerned, has on every occasion proved 
himself to be worthy of confidence. His history, however, shows 
that he on two occasions made his escape from the asylum. 
The first time he went to a neighbouring watering-place, where 
he secured employment, and took lodgings at a figure nearly 
three times as much as he was to earn at his work. He was 
before long discovered and brought back, and after a short 
period of resentment returned to his usual frame of mind and 
went on steadily for about two years, when he again disap¬ 
peared. On this occasion he went to his native town, some 
eighty miles distant, having for some time before escaping saved 
his pocket-money to pay his railway fare. He was brought 
back by his mother, when it was ascertained that he had pro¬ 
posed marriage to a young lady, to whom he represented 
himself as a clerk in receipt of a regular salary. 

Instances of this marked feature of instability might be 
multiplied, but I only advance these two in order to show the 
fallacy of the belief that these improvable cases can be rendered 
capable of independently earning even the most modest com¬ 
petence. A few, and only a very few, are successful; but it will 
be found in nine out of every ten that they have had some advan- 


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4 the improvable imbecile, [Jan., 

tage in the way of supervision, and that there is encouragement 
and a helping hand somewhere. That a number of criminals of 
a certain class are mentally defective in varying degrees of in¬ 
tensity I have no doubt whatever, and many now undergoing 
penal servitude would never have been there at all had they 
been fortunate enough to have had the advantage of suitable 
control, instead of having been left to themselves, cursed with 
congenital infirmity, rendering them the victims of wild impulses 
and rampant passions, ungovemed and unrestrained by defective 
and enfeebled inhibitory faculties. I should be sorry to say 
that all imbeciles of the type now under consideration are 
incapable of the elementary education necessary to fit them for 
holding situations in the humbler walks of life ; for many, as 
far as the possession of this knowledge is concerned, are quite 
eligible, but of what avail is this education when mental in¬ 
stability is almost universal ? Surely of no value at all unless 
such cases are to be continuously subject to superintendence 
and control. Those who are familiar with imbeciles are well 
aware how much depends upon the nature of their environment 
and the character of their associates. One has only to reflect 
upon the lamentable results following their location in wards 
with the insane, to be very forcibly impressed by the vital 
importance of proper surroundings for them, and by the equal 
importance of supervision by persons possessing qualifica¬ 
tions which fit them for undertaking this responsibility. By 
this I mean individuals of quick perception with keen insight 
into character, ready to note and understand the peculiarities 
and idiosyncrasies of those under their care. Above all, such 
persons ought to be endowed with ready sympathy and kind¬ 
ness of heart. It must never be forgotten that but little can 
be done with an imbecile unless his confidence is first gained. 
But where, if we except the training institutions, are we to find 
these necessary conditions ? Most assuredly not in the office 
or workshop of the ordinary merchant or artisan ; there the 
well-being of the unfortunate imbecile would not, in the usual 
course, be considered before business, and did we succeed in 
getting an ex-patient into either of them we should possibly 
find that his “ imbecile temperament ” was unable to cope with 
what might strike him as unsympathetic surroundings: if, 
when instructed as to his work, his superior was in any way 
curt or brusque, then he would resent it, and immediately 


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1899.] 


BY A. R. DOUGLAS. 


5 


become unsettled. Again, if he had any physical deformity, or 
happened to be of abnormal appearance, the jeers of his fellow- 
workmen would cause him acute misery, and an imbecile of 
this type is always more or less sensitive. This is the hardship 
which very often handicaps many of those poor lads, for they 
are often made to feel their inferiority by being made the butt 
for cruel jest and bitter ridicule. I have already said that much 
good work is done in the industrial departments of the training 
institutions. Nearly all these improvable cases are capable of 
being taught trades, and I know several who are really almost 
proficient workmen as joiners, basket makers, tailors, and shoe¬ 
makers. It is most important that in deciding upon a trade to 
be taught, careful selection be made, and individual aptitude 
and predilection considered. Farm labour is eminently suitable, 
and is of course very healthy employment But of what use is 
all this training when one considers that the object of this 
excellent attention will most assuredly, unless placed under 
suitable conditions, tend to gravitate to the workhouse, the 
lunatic asylum, or even the prison ? Surely it is both time and 
money wasted if there is not some reasonable prospect of this 
education being turned to some kind of practical utility. 

There can be no doubt that it is the duty of the State to 
provide some means of permanent guardianship and supervision 
for these cases. Private charity has been the pioneer of the 
movement for the training of the imbecile, and the State ought 
to see that the results of this excellent work, begun and carried 
on with such conspicuous success, are not wasted or lost by 
taking steps to enable the improvable imbecile to cease to be a 
burden, and to help him to lead a useful life. This could 
admirably be met by the establishment of custodial asylums for 
idiots and low-grade imbeciles, and would afford a thoroughly 
satisfactory means of final disposal for a large number of 
improvable cases who, after having undergone their period of 
training, could be drafted into the workshops of the tailor, 
shoemaker, joiner, &c., or do farm or garden work under the 
supervision of a labour master; and I cannot but think that this 
system, or one akin to it, if given a fair trial, would prove a 
great success. 

There is one consideration in respect to low-grade, purely 
custodial cases ; as long as the training institutions receive 
them in large numbers it is not to be expected that such 


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6 INADEQUATE ASYLUM PROVISION FOR THE INSANE, [Jan. 


institutions, supported solely by charity, can, by reason of the 
absorption of staff which the retention of these patients necessi¬ 
tates, extend the scope of their educational departments to the 
degree possible under less adverse conditions. 

The addition to the county asylums of suitably equipped 
annexes for the training of imbeciles is a step in the right 
direction, and it is to be hoped that, failing an effort on a 
larger scale, we may soon see annexes of this description 
attached to all the large county asylums. This departure does 
not, of course, materially approach the question of final useful 
disposal, yet it will attain a very desirable object in securing a 
period of training for many imbeciles who would, from the 
limited accommodation, have been unable to obtain admission 
to any of the older institutions. Dr. Shuttleworth has pointed 
out another advantage in the connection of such an annexe with 
a county asylum, which is that the latter can supply the former 
with a convenient market for its industrial products. 


The Inadequate Asylum Provision for the Insane im¬ 
mediately above the Pauper Class. By David Bower, 
M.D., Springfield House Asylum, Bedford. 

DURING a period of nearly twenty years’ management of a 
private asylum for middle-class patients, and a like period of 
consultation practice in our specialty, I have had constantly 
brought to my notice the difficulty—very often, indeed, the 
impossibility—of finding proper accommodation for insane 
patients unable to pay fees of more than fifteen to twenty-five 
shillings per week, and the difficulty has vastly increased with 
the increasing numbers of pauper lunatics who now crowd out 
the already very small number of private patients provided for 
in county and borough asylums. 

This great want in our asylum system has impressed me 
more strongly recently during the three or four years I have 
been on the committee of the Three Counties Asylum at 
Arlesey, and I consider it sufficiently important to bring before 
you to-day for consideration and discussion. 

Often, when patients have been unable to pay, or to continue 


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1899-1 


BY DAVID BOWER, M.D. 


7 


to pay our very moderate fees of two and a half, two, or even only 
one and a half guineas per week, I have found it impossible to 
get them admitted into hospitals or as private patients into 
county or borough asylums when their friends were quite 
willing and able to pay from i$s. to 25^. per week for their 
care. In such cases the only resort has been to send these 
patients to the large London private asylums receiving paupers, 
or to have them removed as pauper lunatics to the county 
asylum through the relieving officer, who recovers the actual 
cost of maintenance from the patient’s estate. 

This course is very repugnant and humiliating to the friends, 
and it is extremely hard on patients of limited means, but of 
respectable position and education, to have to associate con¬ 
stantly by night and by day with patients very much inferior 
to them in social position, habits, and customs—to dress in the 
odious pauper uniform, to have to eat the coarse, if substantial 
fare which can only be provided for them, and to hear the 
disgusting language of many of their fellow-patients, drawn as 
they are in large numbers from the very scum of society— 
prisoners, loafers, tramps, and other vagabonds. 

Quite recently, in going round our county asylum, I have seen 
thus dressed and situated members of the learned professions, 
the Church, law, and medicine, an officer in the Engineers, the 
son of an artillery officer, an architect’s wife, several respectable 
tradesmen, their wives, sons, and daughters ; and one lady is 
there as a pauper who owns the freehold of part of the land 
forming the grounds of the asylum. In order to make sure 
that mine is not merely an accidental and unusual experience, 
and that the practice of sending patients of the middle classes 
as paupers to county and borough asylums is not confined to 
my immediate neighbourhood, I have looked through the 
tables relating to the social status of patients in the Commis¬ 
sioners’ annual report just issued, and find my impression fully 
confirmed. 

Taking Table XVII in Appendix A for my purpose, and 
dealing only with male lunatics (the occupations and social 
position of the females not being classified with sufficient 
clearness), I find that the average number of the classes who 
ought to be provided for as private and not as pauper patients, 
viz. the professional, commercial, and agricultural groups in the 
Commissioners’ tables down to Class 48 (excluding Classes 19, 


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8 INADEQUATE ASYLUM PROVISION FOR THE INSANE, [Jan., 


21, 22, 23, 24, 41, 42, 43, 46, and 48, and all the classes from 
49 to 99 which comprise the wage-earners and those below them), 
annually admitted to all the asylums, hospitals, &c., in England 
and Wales, is 1684. 

The number of lunatics registered as under care are in the 
proportion of rather more than five to one of the admissions. 
A simple sum shows that there were of these “ ought to be ” 
private patients under care at the beginning of this year 8420 ; 
but the Commissioners’ general summary shows that at that 
time there were classed as private patients in all the institutions 
only 4076, showing that more than one half are under care as 
paupers. If we accept the same ratio for the females of these 
classes as we have found to obtain among the males, it is 
evident that at least 9000 patients, distinctly above the pauper 
class, are being housed and kept as paupers for no fault of 
their own. 

Turning now to the position of those patients who are 
officially classed as private, no less than 1254 are treated in 
county and borough asylums. These are chiefly distributed 
among 31 asylums (the remaining 37 county and borough 
asylums taking practically no private patients). At least half 
of these 1254 are also compelled to associate with paupers, as 
most of the 31 asylums can have no separate provision for 
their private patients. 

I ought here to mention that in a certain number of county 
and borough asylums special and in some cases separate 
accommodation for private patients at low charges has been 
provided. 

The Cornwall, Cumberland, Cheshire, Denbigh, Prestwich, 
Northampton, Leicester, and Portsmouth asylums have for a 
considerable time accommodated 30 to 40 private patients 
each. Exeter has 67. Three Yorkshire county asylums have 
about 70 private patients each, and, to the credit of the York¬ 
shire Lunacy Authorities, a separate asylum is now being built 
in Wharfedale for 210 private patients. Birmingham city, the 
Isle of Wight, and Leicester borough asylums are following 
suit. 

The public asylums in the south of England which have in 
recent years proved themselves most enterprising and successful 
in catering for non-pauper patients are those presided over by 
the active and energetic secretaries of this and the South- 


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1899] 


BY DAVID BOWER, M.D. 


9 


western Divisions of the Medico-Psychological Association, 
viz. the City of London Asylum with over eighty private patients 
at a pound a week, and the Dorset County Asylum with a 
similar number at a pound a week and upwards. 

I think I have said enough, and have troubled you with 
statistics enough, to show the want which exists. How, then, 
can this want best be met ? That is the question I claim your 
assistance in answering. 

Insane persons are mainly provided for in four ways, viz.: 

(a) in single care; ( 6 ) in licensed houses; (c) in hospitals, and 
( d) in county and borough asylums. To which of these are we 
to apply ? 

(a) Single care .—I think we might to some extent hope 
for an extension of home treatment if the medical officers of 
the county and borough asylums were available for directing 
the treatment of patients at their own homes, either at the 
expense of the county, or of the patient where he could afford 
it This would also be to the professional advantage of the 
medical officers and the gain of the community, as the former 
would thus be able to see cases of insanity in their earlier 
stages, and assist in the prevention of disease, instead of their 
work being restricted, as it now usually is, inside the boundary 
fence of their own asylums. 

(b) Licensed houses or private asylums .—These are already 
full, and a paternal, not to say suspicious legislature has for 
good or ill decreed that they shall not be extended nor increased 
in number. Private enterprise cannot then be looked to to help 
us in our dilemma. 

(c) The hospitals —one of the best of which we visited at 
this time last year. These are our great mainstay at present 
for providing accommodation, and that of a luxurious and 
splendid character, for the greater half of our non-pauper 
patients, but they are in most cases practically full, at least as 
regards the lower paying patients who cannot afford more than 
l$s. to 25 s. per week. 

The stream of benevolence having ceased to flow in the 
direction of the hospitals, we cannot expect any great assistance 
from them, although the Commissioners in their latest report 
say that the abstract of annual accounts of the hospitals 
“ discloses in some instances the receipt of large incomes, which 
should leave room for the exercise of more charitable provision 


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IO INADEQUATE ASYLUM PROVISION FOR THE INSANE, [Jan., 


for patients of moderate means who stand in need of institutional 
care and treatment at low rates of payment, in addition to 
providing and improving accommodation for patients of the 
wealthier class.” 

( \d) The County and Borough Lunacy Committees will, to 
a large extent, have to be looked to for providing the necessary 
accommodation required, either where the population is dense, 
by building separate asylums for private patients paying low 
rates sufficient only to pay for their housing and maintenance, 
as Yorkshire is doing, or where the population is sparse to add 
to the existing asylums properly equipped departments for 
private patients paying low rates, either in separate blocks 
attached to the main building, or preferably, where sufficient 
land is available, in separate self-contained buildings of not too 
high elevation, with grounds round them devoted to the exclusive 
use of the patients residing there. Authority to provide this 
accommodation was specially granted to the Local Lunacy 
Authorities by the Lunady Act of 1890, and I believe the 
few authorities who have taken advantage of this clause of 
the Act have seen no reason to regret the steps they have taken. 
In fact, I know in at least one case a handsome sum is handed 
over each year in relief of the rates. 

I mention this last fact not with approbation, but as showing 
that no fear of loss need deter any authority from making this 
most necessary provision—a course which would not only tend 
to diminish the numbers of the pauper insane, but would at the 
same time be doing an act of justice to the respectable and self- 
respecting lower middle classes who have been so long ne¬ 
glected in this important matter. 

Discussion. 

At meeting of the South-Eastern Division, Bedford, 10th October, 1898. 

The President said that he did not know that there was anything more urgently 
necessary than the provision of proper accommodation for the insane of the lower 
middle class. It was extremely desirable that England should assist those who 
were not of the pauper class, and should preserve that feeling of independence 
with regard to Poor Law help which had always been the characteristic of the 
nation. There was one thing which they should specially consider—the question 
of a profit being extracted from those patients. If those unfortunate people should 
have to aid the ratepayers, that would be a most undesirable outcome of the change 
of the law. He thought that such a scheme should be adopted as had been indi¬ 
cated by the Scottish Commissioners; that if the English Act in this particular 
were to be extended to Scotland, the cost per week of those received into county 
asylums should^ not exceed a moderate return upon the expenditure on the part of 
the counties concerned; that was to say, whatever might be spent upon them, 


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BY DAVID BOWER, M.D. 


1899.] 


I I 


including the repayment of the necessary capital expenditure, should be the rate 
per week chargeable; effectually preventing the misfortunes of those in narrow 
circumstances issuing in a payment in aid of the ordinary ratepayers. 

Dr. Emmerson said that in the practice of his profession he had constantly been 
called upon to certify for removal to asylums, and he had in his mind respectable 
people who had never been on the rates in any way, and yet the difficulty arose as 
to where they should go. They did not wish to be sent to a pauper asylum ; but 
too often there was nothing else for it, and they had to become nominally paupers, 
arrangements being privately made with the guardians that their expenditure should 
be refunded by the friends. That did not seem a fair thing to the friends nor to 
the ratepayers, but meanwhile there was no possibility of suggesting an alternative. 

Dr. Percy Smith said he was surprised to hear the remarks of the last speaker. 
Cases similar to those mentioned by him were admitted at Bethlem without pay¬ 
ment, or on very low rates. There was always a great number of people who, by 
reason of their insanity, lost their position, and became members of lower social 
strata; but for the acute and curable cases there was accommodation, although no 
doubt it might be largely increased in some parts of the country for those patients 
of limited means, whom one desired to keep out of county asylums. As to the 
question of profit which the President had raised, there was nothing to say as far 
as Bethlem was concerned,or where patients were paying two guineas a week; but 
one would like to know with regard to Stone and Dorchester, where one guinea a 
week was considered sufficient, whether the whole of the payments were devoted 
to the benefit of the patients paying that rate. 

Dr. Richards said he thought it was pretty well agreed amongst the medical 
profession that asylums other than pauper asylums were absolutely necessary for 
persons of limited means. How were they to suggest the best scheme to the 
official bodies who had the power to create them ? He thought that they should 
recommend Dr. White’s plan of an appendage to the pauper asylum, or an entirely 
separate institution as at Wharfedale. The latter proceeding seemed to him the 
better one. If the county authorities had separate establishments just paying their 
way, where patients could be admitted at the low rates so desirable for that class 
of patients, it would be much better to have it unattached to the pauper asylum, to 
prevent the people from confusing the private with the pauper. At Wharfedale 
they got rid of the idea of making profit for the parent establishment. Those con¬ 
nected with asylums should educate the county councils or their committees in 
that direction. 

Mr. Bayley said that having been connected for many years past with one of 
their large hospitals, he might be allowed to state his views. He had also been 
superintendent of a county asylum for a considerable time. It must be remembered 
that by far the larger number of hospitals were not endowed, but were entirely 
dependent upon the profits they could make from the patients they received. He 
believed that Bethlem and St. Luke’s were the only two that were endowed. 
Fortunately they had funds which allowed them to receive patients free of charge. 
He thought they would be wiser if they did not admit patients free of charge, but 
at a very low rate, say fifteen shillings a week, and if they made no reduction until 
they had made inquiry into the circumstances of the patients and their relatives. 
During the time he had been at St. Andrew's Hospital he had frequently received 
patients who had been in Bethlem, and whose friends had volunteered to pay three 
or four guineas a week. With regard to other hospitals, there was no doubt that 
more might be done by some of them. When he went first to St. Andrew’s Hos¬ 
pital they had only eighty private patients, a very few subscriptions, and a very 
limited income. The greater part of their income had been utilised to relieve the 
ratepayers of the county. But fortunately they had a committee who saw things 
in the right light, and who were willing to do what they could to extend the hos¬ 
pital. They got rid of the pauper patients, and they never put a patient on the 
charity without ascertaining whether his friends were able to pay the amount, and 
that his former position entitled him to the benefits of the institution. They now 
had nearly four hundred patients, and the greater number of them paid little more 
than twenty-five shillings per week. Close upon one hundred were kept either free 
of charge or for considerably less than the cost of maintenance. This, as he had 
said, had been done by the energy of the committee of management, and he could 
not help thinking, if some of the other hospitals in the kingdom would only launch 


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I 2 INADEQUATE ASYLUM PROVISION FOR THE INSANE, [Jan, 


out in the same direction, an immense amount of good might be done, and a large 
number of those deserving cases might be relieved. They could not depend on 
subscriptions. The public did not look upon these cases as requiring charity. If 
the hospitals were to exist they must make an income for themselves. With regard 
to the step which had recently been taken in certain county asylums, he looked 
upon it as a move in the right direction. There was a large number of patients 
whose former position rendered them hardly fit to associate with the class they had 
in the hospitals. They were not at home there, although they were not paupers. 
For educated people he thought hospitals were the proper places, but for the lower 
middle class he thought that the accommodation proposed in pauper asylums was 
what they wanted, and he hoped all the counties would do as they had done at 
Stone and Dorset; but at the same time he did not think there should be a profit 
made. In some county asylums very large profits had been made: patients had 
been paying seventeen shillings to one pound a week ; they had been clothed and 
fed as paupers, and the profits had been handed over to the county. He did not 
see why they should not be received there for the actual cost. 

Dr. Percy Smith explained that the circumstances of every case were considered 
at Bethlem. The relatives had to explain what their means were, and why they 
were asking for charitable assistance; therefore if Mr. Bayley had had patients 
from there who were willing to pay, the committee had been deceived. 

Dr. Neil said, owing to his late arrival, he was sorry he had not had the plea¬ 
sure of hearing Dr. Bower’s paper. The Warneford asylum was endowed to the 
extent of about ^2000 a year. They made no profit as a whole, and but few 
patients paid more than the cost of their maintenance, which last year was twenty- 
eight shillings. The regular charge was two guineas per week, and he thought 
that there were from eighteen to twenty who were paying part of the maintenance 
of those who paid less. None were kept free, for the committee had always refused 
such cases, but some were paying as low as five shillings. If reduction on the 
regular charge was requested, a petition must be submitted to the committee with 
a full and candid statement of the pecuniary circumstances of the patient and his 
relatives; also whether there were friends who could assist and ought to do so. A 
medical statement of the case was also required. When all this information had 
been laid before the committee the fee was reduced to the amount the committee 
thought reasonable. The result was at the end of each year the gross receipts 
from the patients did not pay the gross cost, and the difference was made up by 
their endowment They had so far had a balance every year on the right side; 
but were it not for the endowment it would be on the wrong side. What surprised 
him was that the asylum had never been full. He would very much like to know 
what became of those applicants they did not receive, because, so far as he was 
aware, there was no hospital in England which took patients at a lower average 
charge than they did. The persons they relieved were the poorer members of the 
educated class The majority were either clergymen or their near relations. With 
regard to the extension of such accommodation, few charitable people left money 
to asylums. He thought that physicians who practised among the wealthy might 
do good service by advising people to leave money in this way. At Warneford 
applicants from Oxford had a preference, and he did not think that they had ever 
refused a case from Oxfordshire. 

Dr. Moody said, like all previous speakers, he had been very much struck by 
the numbers of people of the class mentioned who had been admitted to Canehill 
from time to time. With regard to Bethlem Hospital, it was a temporary home 
for many, who were very often drafted to them at later stages of the malady. He 
had at the present time a barrister, a doctor, and others from there; so really that 
institution did not supply the want Dr. Bower indicated. He lately saw some 
patients in a county asylum who were dressed differently from the others, and on 
asking the reason he was informed that they were allowed to wear their own clothes 
by paying extra. He did not think that was quite what they wanted. It seemed to 
him that unless there was distinct accommodation provided for these people it 
would be very much better to adopt Dr. Richards’ suggestion to have separate 
places altogether. There was a temptation, if a patient became a little excitable, 
to place him in the pauper wards for a time. Claybury Hall, in London, had been 
adapted for private patients, and as soon as they imagined that Canehill patients 
had sufficient means an inquiry was instituted, and they were drafted to Claybury 


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BY DAVID BOWER M.D. 


13 


1899.] 

at once if their friends permitted. He very strongly felt that if they could have 
separate buildings altogether, quite distinct from the county asylums, it would be 
a great advantage. 

Dr. White said he would give them a little history of how they had developed 
at Stone. The Act came into force in 1890. Previous to that he had been struck 
by the large number of patients who were evidently paid for by their relatives, and 
on making inquiry he found ihat in many instances they paid 115. Sd. per week, 
which was and is at present the charge for rate-paid patients. But where did the 
Corporation come in ? At 1 is. Sd. per week they were getting nothing for the 
lodging of these patients ! Why should they not be placed upon a proper footing P 
He ascertained the number of these patients, and one outcome of it was that they 
had abolished as far as they could the word “ pauper," and substituted for it “ rate- 
paid." He thought the sooner every one abolished the word “ pauper" the better. 
As they had learned that day, a very large proportion of those patients who 
were called paupers were not paupers. He thought to himself that the City was 
one square mile, they had accommodation for four or five hundred patients, but 
the City was becoming more and more commercial, and the premises were passing 
into the hands of caretakers, and there was every possibility that they would have 
more and more spare accommodation. He found on inquiry that there were any 
number of patients who had no claim whatever on the City rates, but because they 
became insane in the City they were taken to the various police courts of the City, 
and were sent down to Stone and allowed to remain there. He ferreted out all these 
cases, and made up his mind to have them drafted away to their proper districts. The 
result had been that he handed in a list to the Committee of as many as he could 
find out, the Committee handed it to the City authorities, and they were soon 
reduced by a hundred in their institution. In the meantime the Act of 1890 was 
passed. He said here was an opportunity of conferring a great benefit upon 
a suffering community. The Act empowered them to open out the care and treat¬ 
ment of insane for the middle classes. For a long while he had enormous opposi¬ 
tion, but after a time the scheme was carried, and in 1892 they began to receive 
private patients, and up to the present time they had steadily increased in numbers, 
until they had now 114 of that class. They charged £1 is. a week for board, 
lodging, washing, and general and medical attendance, and gave the patients bacon 
and eggs for breakfast in addition to the ordinary fare, and puddings for 
dinner. They sat at separate tables in the dining hall, had separate seats at the 
entertainments and at chapel, went out to picnics more than the others, and played 
in the tennis courts. They also had cricket matches every week, and they were 
encouraged in every way. Their friends, of course, clothed them. As far as they 
could, these patients occupied separate wards, but in these wards there were a few 
rate-paid patients who assisted in the menial work, and if a separate building were 
employed they would find without these patients they had an enormously increased 
cost, and they would not be able to do it for the money. They must find their 
workers among the better set of their rate-paid patients who were accustomed to 
menial labour, and who would assist in doing the menial work of the ward just as 
a servant would do in the house. Three or four rate-paid patients only might be 
in the same ward, but they did not sleep in the dormitories attached to that ward. 
This extra accommodation could be made by making an extension for private 
patients on the same estate, and having the people come up from the rate-paid insti¬ 
tution to assist at the private institution with the menial labour. Otherwise, as he 
had said, they would be saddled with a greatly increased cost. He believed there 
was a fine future for the county and borough asylums if they opened out in the 
way the Act indicated. It was a magnificent opportunity for helping the class who 
ought to be helped, and it would pay, not in relieving the rates, because not one 
farthing of that money they had made had they ever handed back to the Corpora¬ 
tion. It was all spent in improvements, and they were now spending .£70,000 in 
improvements, which they had asked the Corporation to give them. They were 
making new infirmary wards, a new laundry, a detached chapel or church, and the 
present church was to be converted into a recreation hall, &c. Therefore he was 
firmly convinced that these blocks might be built as appendages to county asylums, 
but not as separate institutions. There they were touching upon the province of 
the hospitals. They only desired to touch the fringe of the question. They 
wanted a hospital for each county before they could touch the whple question, or 


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14 INADEQUATE ASYLUM PROVISION FOR THE INSANE. [Jan., 

before they could accept any case that came before them. The class for which 
they were hoping to cater was a very large one. Dr. Bower had told them that 
there were 9000 above the rate-paid class who ought to be catered for, and it was 
for them that they ought to do their utmost to extend every benefit they possibly 
could; and he honestly believed that by doing so they would really gain for 
themselves any amount of thanks from people yet to come. 

Dr. Richards asked whether the profits made out of private patients were 
devoted to the pauper portion of the asylum as well as the private. 

Dr. White said certainly they were; both must participate. But it had never 
been that those profits were so large that they had not had to go and ask for a grant 
for repairs. 

The President said Dr. Emmerson held that it was not fair to the ratepayers 
to provide accommodation for the poor private insane. If the superintendent of a 
county asylum refused to admit these as paying patients they would simply come as 
paupers, and that certainly did not relieve the rates. But it was not an honest, it was 
not an English method. At the beginning of the century the flow of charity towards 
the hospitals was very remarkable, but the circumstances were now quite different. 
Some years ago, when Dr.Clouston was taking credit for having done much chari¬ 
table work, a Radical paper, now happily extinct, said that was not what they wanted 
at all. It asseverated that everybody had a right to adequate treatment apart 
from charity. They had to deal with people classed as they found them. The 
middle class, the professional class, were not so difficult to deal with, as there were 
not so many of them, and as their circumstances were often easy ; but there was 
an immense number of the poorer class just above the “ pauper ” class spread 
over England. The founder of Murray's Asylum diiected that his money should 
not be used as a grant to aid the ratepayers, but that it should benefit those who 
had no claim to be called paupers; that was to say, he desired it to benefit those 
who did not belong to that class of society who immediately fell into pauperism 
when afflicted with insanity, but the educated middle class fallen on evil days. 
With regard to the great army of poorer workers, whose interests ought to be con¬ 
sidered, and whose self-respect ought to be maintained, he thought that Dr. 
White was certainly right in providing for them at the minimum rate. There was 
hardly an asvlum where there was not an old Bethlem patient, so that Dr. Percy 
Smith could not rightly claim it as sufficient. Besides, it was at the end of a year 
that the pecuniary strain generally began. The Scottish Commissioners fixed a 
rate of payment for these cases. They formerly said that they did not consider 
that the Royal Asylums were doing their duty unless they took patients at ^25 
a year; ^35 would be nearer the mark now, considering the average rates for 
paupers in the Scottish asylums. But he had already spoken in entire concur¬ 
rence with the later views of the Commissioners. He certainly thought a great 
many deserving people in England would find difficulty in paying^i a week. The 
question Dr. Neil had raised was extremely interesting. For many years he (the 
speaker) had kept a register of the reasons of applications for admission not carried 
out, and found that a great number of them recovered or became manageable at 
home. Many became pauperised ; the friends recognised that the county asylum 
was most suitable ; some preferred other hospitals on considering relative advan¬ 
tages ; and lastly, there was a certain number who delayed and were admitted 
later. 

Dr. Bower said the object of his paper had been far more than gained, for it 
was extremely gratifying to him that the choice of the subject had evoked such 
valuable expressions of opinion from the representative of the general practitioners, 
from the superintendents of hospitals, and from public asylum men, who had all 
given them valuable information. He thought probably in the more densely popu¬ 
lated districts separate asylums would have to be adopted, and he had in his mind 
the absolute impossibility of the superintendent of a large asylum undertaking 
private patients as well as paupers. 


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1899.] THE WORKMEN’S COMPENSATION ACT. 


IS 


The Workmen's Compensation Act and the Fatal Acci¬ 
dents Inquiry (Scotland) Act in Relation to Asylums . 
By J. G. Havelock, M.D., Royal Asylum, Montrose. 

The necessity of a cognizance of those Acts of Parliament 
affecting asylums in their capacity as large employers of labour 
has become more obvious of late by the operation of an Act 
which came into force in July last—“The Workmen’s Com¬ 
pensation Act ”—where, for the first time in British law, a 
responsibility has been cast upon an employer to pay damages 
or compensation for personal injuries which are not the result of 
any negligence or other unlawful act, either of himself or his 
servants for whose conduct he is legally responsible. 

By the common law a master has always been bound to 
take reasonable precautions to ensure the safety of his servants, 
and is liable for damages where the servant has suffered an 
injury due to the want of such reasonable precautions. The 
servant takes on himself all the ordinary risks incidental to the 
employment, but the employer is liable for what could be seen 
and prevented, was bound to select competent persons to super¬ 
intend and carry on the works, and was bound to furnish proper 
tools and appliances. At common law the master was not 
liable where the servant accepts danger as one of the ordinary 
risks incident to his employment, where the accident was caused 
by the negligence of a fellow-workman (known as the “ doctrine 
of common employment ”), or where the workman was guilty of 
contributory negligence. 

The Employer’s Liability Act of 1880 swept away the defence 
of “ common employment ” so far as the master was concerned, 
and rendered him liable for injury caused by reason of the 
negligence or carelessness of a manager, or defect in the con¬ 
dition, &c., of the works or plant used in the business of the 
employer. This Act was open to the objection that its 
phraseology is provocative of much litigation, ( l ) and the work¬ 
men thought that the Act did not go far enough, and as the 
result of further agitation the Workmen’s Compensation Act 
(1897) was passed. 


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16 THE WORKMEN'S COMPENSATION ACT, [Jan., 

Workmen's Compensation Act. 

Under the provisions of this Act there is for the employer 
what may be termed universal liability for accidents falling 
under its scope. Previously, negligence in one form or other 
was the foundation of every claim for damages at the instance 
of a workman against his employer. Now, however, every 
employer is liable for all injuries through (i) inevitable accident; 
(2) fault on part of fellow-workman or fellow-servant; and (3) 
any other cause. There are just two exceptions :—(1) where 
the injury is attributable to the serious and wilful misconduct of 
the workman ; (2) where the injury has not arisen out of, or in 
the course of the employment. 

The Act is, however, limited to certain trades. Amongst 
them we find employment on or in any quarry, factory, or any 
building which exceeds thirty feet in height, and is either being 
constructed or repaired by means of a scaffolding, or being 
demolished, or on which machinery driven by steam, water, or 
other mechanical power is being used for the construction, 
repair, or demolition thereof. 

“ Workman ” includes every person who is engaged in an 
employment to which this Act applies, whether by way of 
manual labour or otherwise, and whether his agreement is one 
of service or apprenticeship, and is expressed or implied, is oral 
or in writing. 

“ Factory '* includes every laundry worked by steam, water, 
or other mechanical power. 

It is evident, therefore, that various employes about an 
asylum will frequently fall within the scope of the Workmen's 
Compensation Act, such as joiners, masons, painters, laundry- 
maids, &c. 

Before the passing of this Act a workman had two modes of 
getting damages—common law and Employer’s Liability Act, 
and this Act provides him with a third. 

The sums payable under the Workmen's Compensation Act 
are— 

In case of death .—A sum equal to the workman’s earnings 
during the three years prior to the injury, or during such period 
as he may have actually been employed. In either event the 
ium payable shall not be less than ^150, nor more than £300. 

These sums are payable, however, only when deceased leaves 


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1899] 


BY J. G. HAVELOCK, M.D. 


17 


persons wholly depending upon him. If they be dependent 
only in part the sum may be settled by agreement, or failing 
that by arbitration. Where deceased leaves no dependants the 
employer must pay a reasonable sum for medical and burial 
expenses, not exceeding £10. 

In case of non-fatal accidents .—1. No payment requires to be 
made during the first two weeks of disablement. 2. After the 
first two weeks the sum payable will be one half of the average 
wage of the injured person before accident, but not exceeding 
£\ a week. After six months this may be commuted by a 
lump sum. 

It is obvious, therefore, that this new Act has thrown upon 
all employers a liability for what is known as “ inevitable 
accident,” and it is probable that the managers of many 
asylums will effect insurance against the possible demands made 
upon them in the case of accidents to their employes. 

A plan of insurance has been tentatively entered into at 
Montrose Asylum, whereby the risks to the employes are fully 
covered—at common law, Employer’s Liability Act, and 
Workmen’s Compensation Act. 

For this purpose the employes have been divided into two 
classes : 

1. Those insured against claims at common law, and under 
Workmen’s Compensation Act, and Employer’s Liability Act 
These include the painters, plumbers, joiners, engineers, grieve, 
firemen, slater, and the laundresses. The premium paid is at 
the rate of ys. 6 d. per cent, on the wages paid. 

2. All the other employes are insured only against claims 
at common law and under the Employer’s Liability Act. In 
their case the premium paid is at the rate of 2 s. 3 d. per cent, 
on the wages bill. One great objection which may be urged 
against this system of insurance is that the company inserts as 
a condition on their policy that they may defend a claim in a 
court of law in the name of the employer. 

As the Workmen’s Compensation Act very expressly provides 
that all questions arising under this Act between employers 
and employed may be settled by arbitration, one feels 
naturally reluctant to throw one’s self entirely into the hands of 
an Insurance Company who, under the name of the employer, 
on principle, may fight the matter out to the bitter end entirely 
irrespective of the wishes of the employer. 

XLV. 


2 






18 THE WORKMEN’S COMPENSATION ACT, [Jan., 

A better way for providing for the risks as far as asylums 
are concerned may be found in the formation of an Accident 
Scheme or Fund. This is expressly recognised in the Act, but 
the scheme must be approved of by the Registrar of Friendly 
Societies as not being less favourable to the general body of 
the workmen and their dependants than the provisions of the 
Act. The employers must necessarily contribute largely to 
the scheme; the workmen get the benefit should an accident 
happen, and should no accident happen the funds are always 
increasing. Under such a scheme as this the workman would 
get paid during the first fortnight’s disablement, which of course 
is not allowed for by the Act. 

In ordinary asylum work, fortunately, serious accidents are 
not common, and it has been the custom at Montrose to allow 
full wages to any servant injured in the service, and to treat 
every case in a liberal way on its own merits. 

This meets the circumstances adequately where an injured 
person leaves no dependants, but cases may arise where com¬ 
pensation is demanded on their behalf, and it seems a sound 
and business-like policy to effect insurance against such claims. ( 8 ) 

Fatal Accidents Inquiry (Scotland) Act . 

The other recent Act of Parliament to which I shall refer is 
one which makes provision for public inquiry in regard to 
fatal accidents occurring in industrial employments or occu¬ 
pations in Scotland. 

This Act extends to and includes all cases of death of any 
person or persons, whether employers or employed, engaged in 
any industrial employment or occupation in Scotland, due, or 
reasonably believed to be due, to accident occurring in the 
course of such employment or occupation. 

“ Industrial employment or occupation ” is defined to mean 
any employment or occupation for, or in the performance of, 
any manual labour, or the superintendence of any such labour, 
or the working, management, or superintendence of machinery 
or other appliances, or animals used in the prosecution of such 
work. 

The Act goes on to state that the Procurator Fiscal shall 
collect evidence in the case of such a fatality, and lay it before 
the sheriff, who thereupon shall pronounce an order for a public 
inquiry. The inquiry shall be before a sheriff and jury, and 


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18 9 9 -] 


BY J. G. HAVELOCK, M.D. 


19 


evidence having been led, the jury must return a verdict stating 
when and where the accident took place, and the cause or 
causes of the death or deaths. 

Relatives and employers and other parties interested may 
make an appearance at such inquiries. 

The verdict, evidence, and productions must be forwarded to 
the Crown Agent; the whole procedure, in fact, resembles that 
of a trial by jury in a Sheriff-court. 

The Act does not any way affect the existing law and 
practice relative to the duties of Procurator Fiscals to inquire 
and report to the Crown Agent in regard to deaths from 
accident. 

The interest of this Fatal Accidents Inquiry Act in its bearing 
on asylums depends upon the interpretation which is placed 
upon the definition of “ persons engaged in any industrial 
employment or occupation.” The expression “ employment or 
occupation for or in the performance of any manual labour , or 
the superintendence of any such labour,” seems to me to include 
the large majority of asylum workers, for these are all, at one 
time or another, engaged in some kind of manual labour. This 
has been interpreted in a much wider sense, as “ any person or 
persons, whether employers or employed,” has been assumed to 
cover all patients who are industrially employed. 

In this connection it may be pointed out that in the Fatal 
Accidents Inquiry Act asylums are not specifically excepted 
from the provisions of the Act, as they are, for instance, in the 
Factory and Workshops Act, which was passed in the same 
year. 

(1) This is probably not an objection in the eyes of the legal practitioner.— 
(2) The writer is indebted to the excellent manuals on the Workmen’s Compen¬ 
sation Act by Wilson and Willis. 


Discussion. 

At the meeting of the Scottish Division, Edinburgh, 10th Nov., 1898. 

The President said that this was a matter which required attention. After 
considering the question carefully he thought that it was better not to insure. There 
was a fatal accident lately in Perth in a private house, and a public investigation 
took place. The gentleman concerned wished to do something for the widow and 
family, but the insurance company, who protected their own interests in the first 
place, and the interests of the contractor in the second place, prevented him from 
doing anything to help. The company insisted that the case must be fought out 
in the courts. He thought that it would be most undesirable for asylums to figure 
in the courts in respect of cases of that sort. He considered that an old established 
business was sufficiently powerful in its organisation and its finance to deal with 
any case that might occur, and that the asylums were in a similar position. He 
would remind the members that they were still waiting the passing of the English 








































THE WORKMEN’S COMPENSATION ACT. 


20 


[Jan., 


Lunacy Bill before proceeding with their scheme for pensions and gratuities to the 
officials of Scottish asylums. 

Dr. Clouston said that at Morningside they had done nothing as yet with 
regard to the Workmen’s Compensation Act. He asked Dr. Havelock if they 
insured on the initiative of the committee or after taking legal advice. 

Dr. Havelock said that it was done as a matter of business. They considered 
it to be a sound business principle to insure, for a time at least, against the 
liabilities imposed by this new Act until they saw how it would affect the asylum. 
The insurance companies did not know how the Act might work. 

Dr. M'Dowall said that in various English asylums, judging from the number of 
circulars he received, the matter was commanding very general attention. He did 
not know of any asylum where this form of insurance had been adopted. In the 
West Riding of Yorkshire they decided to do nothing. In Northumberland they 
thought that it was scarcely worth while insuring. They always treated their 
employes with great generosity, and never had a man seriously injured; but if a 
man was off work owing to some slight injury he always got full wages. They 
had people suffering from serious sickness, and their rule was that they got half 
their wages as long as they were ill. If the illness ran on for some months, and 
the man was not getting better, then they took into consideration the advisability 
of pensioning him off. They had been very liberal in granting pensions. In 
Northumberland there seemed to be no probability of their insuring themselves 
against these risks, especially when they took into consideration that they were 
not allowed to interfere benevolently, and that litigation might be raised by the 
insurance company in spite of their protests. He was convinced that his com¬ 
mittee did right in declining to insure against any risks of that kind. 

Dr. Rutherford said that his Board had not thought of insuring. In the case 
of district asylums, with the ratepayers at their backs, they should be considered 
more as charitable institutions than as factories. At any rafe, he thought that if 
it was right that a person should have compensation he should get it; if it was the 
law that he should have compensation he should get it. His own feeling was that 
they should not insure, and that each case should be dealt with on its own merits. 
Accidents happened so rarely that there was very little risk under the Act. 

Dr. Hotchkiss said that the Gartnavel Board had never discussed the question, 
and had done nothing with regard to it. In slight accidents the attendants, in his 
experience, not only got their full wages, but they were often members of Friendly 
Societies, and got an allowance from them, so that they actually benefited pecu¬ 
niarily by being laid up- 

Dr. Carlyle Johnstone said that it seemed to him that compensation under 
this Act was a strictly legal question, and one which would have to be dealt with 
by their Boards of Directors. He was much indebted to Dr. Havelock for 
bringing up this matter before the meeting, and he should place it before his own 
Board. 

Dr. Clouston said that he did not agree with Dr. Johnstone when he indicated 
that this was not a suitable subject for discussion. He thought that they should 
discuss whatever related to the welfare of their institutions. There was very little 
done without their initiation, and he thought that this was a proper thing to bring 
before their directors; but before advising anything they ought to be sure as to 
the interpretation of the Act, and as to whether it applied to them or not. He 
would therefore place the question before the legal members of the Board of the 
Royal Edinburgh Asylum. Meanwhile he would refrain from giving any opinion, 
as the Act was new to him. 

Dr. Havelock said that the great objection to insurance was that the company 
insisted, as a condition of the policy, that they might defend the claim in a court 
of law in the name of the employer. At Montrose, when an accident happened, 
the managers had always paid the full wages and continued the person in the 
service for an indefinite length of time. That had been the case in the past, and 
he had no doubt that it would be the case in the future. Still, when the law gave a 
class of servants right to demand compensation under the Workmen’s Compensa¬ 
tion Act, it was perhaps business-like to do as they had done, and he thought 
that the managers of the Montrose Asylum acted in a business way when 
they insured themselves against any possible risks. The insurance was of a 
temporary nature ; it terminated at the end of a year, and it might or might not be 


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x899] 


BY J. G. HAVELOCK, M.D. 


21 


renewed. Perhaps, as Dr. Johnstone indicated, this was not a matter which 
interested the Association from a psychological point of view, but he had always 
found it desirable to have as much information as possible regarding all affairs 
that might touch an asylum in addition to purely medical questions. 

Dr. Ireland said that it seemed quite out of the way for an important asylum to 
go to an insurance company to save themselves from small risks. They could 
imagine small asylums insuring against these risks where they w'ere anxious to 
avoid possibly large expenses. They had a right to discuss the law and to 
consider it carefully, because they were all supposed to know something about it. 
They all had attended lectures on medical jurisprudence, and on that particular 
part of the law they generally understood things better than the lawyers 
themselves. 

The President suggested that they should adjourn the debate until their spring 
meeting, when Dr. Clouston would be able to speak with authority on this branch 
of the subject. 

Dr. Clouston said that he would try to get an opinion by that time, and the 
suggestion of the President was agreed to. 

The President said that the second section of Dr. Havelock’s paper was before 
them some little time ago, and he called upon Dr. Turnbull to refresh the memory 
of the meeting. 

Dr. Turnbull read the extract from the minute of the previous meeting, in 
which the subject had been referred to. 

Dr. Johnstone said that in the first place it seemed to him that questions of 
law were involved which they were not competent to discuss. Speaking as a 
layman, it seemed to him that the law did apply to asylums, but he did not bring 
that opinion before the meeting as having any value. It was a question for a 
lawyer. At present all cases of fatal accidents must be reported to the Fiscal, and 
it rested with the Fiscal to take what steps he considered necessary. It was not 
for them as members of the Association to criticise the procedure of a Crown legal 
officer or to suggest to him an interpretation of thelaw. He knew that some of them 
had a good deal of feeling in regard to the publicity brought about by this Act, but 
he did not think that they had any reason to fear that publicity. On the contrary, he 
thought that they should welcome it. They should continually endeavour to persuade 
the public that asylum work was not work done in darkness. There was nothing 
done in asylums of which they were ashamed. Asylum management was, in fact, 
a large and important part of public work, in which the public were interested. As 
regards the claims of their patients another question arose. Was it to the advantage 
of their patients that the public inquiry imposed by the Act should be held ? It 
seemed to him that it would be to their detriment. The interests of their patients 
were sufficiently protected under existing arrangements. In the event of this Act 
applying to fatal accidents in asylums their patients would be liable to be exposed 
in a public court of law. Their actions, their sayings, their demeanour, and their 
private affairs would all be published in the public newspapers. This, they could 
easily conceive, would be a distinct prejudice to their interests and a source of 
distress to their friends. It seemed to him, on the whole, that the insane would 
suffer if included within the scope of this Act, but in other respects he had no 
objections to the Act at all. He did not think that asylum officials would suffer, 
but if they did suffer, it could only be because they had deserved it. 

Dr. Turnbull said he thought it was very desirable that they should know where 
they stood, because in the short time that the Act had been in force there had been 
two opposite interpretations of it. The suicide of a patient did not come under the 
scope of this Act, but was provided for by the old form. If they were employing 
a patient in some work intended for the benefit of his health, and he had an 
accident, it should be inquired into by one procedure or another; and they 
came to the point, did the mere fact of employment in the wide sense of the word 
mean that they were to be brought into public inquiry to make sure that all 
necessary precautions had been taken, and to see that no patients were subjected to 
undue risk ? Personally it seemed to him that they got at it by the old procedure 
quite well,but he shared with Dr. Johnstone the feeling that if there was any objection 
to having these things publicly inquired into, the objection should not come from 
their side unless they could say that it would do harm to the patients. The Pro¬ 
curator Fiscal in his (Dr. Turnbull’s) district said it was a very nice point indeed 



22 


THE WORKMEN’S COMPENSATION ACT. 


[Jan., 


whether the mere filling up of the time of the patients with occupation for their 
benefit came under the heading of employment in the sense in which it was 
intended to be used in the Act. It was, however, desirable that they should know 
exactly how the new Act affected them. 

Dr. Clouston said that he felt strongly that their patients were not employed 
in any industrial occupation in any ordinary sense of the term, but that they were 
under medical restorative treatment—a treatment which might be profitable or 
unprofitable to the asylum. He was astonished that there was a public inquiry 
into the case at Rosewell. That seemed to him to be utterly beyond the scope of 
the Act. An insane person was specially protected by the Lunacy Acts and the 
Lunacy Commissioners, and was, as an insane person, excluded from this particular 
Act. He received no wages for his employment; there was no contract. There 
was no doubt a tendency—perhaps a proper one—to say that all accidents which 
happened in asylums happened through carelessness, and a jury might be unduly 
harsh in their verdict in the case of a patient. In that way there would be un¬ 
merited risks to the reputation of their institutions, and they all knew that it was 
perfectly providential that they had no accidents in their steam laundries, and yet 
the patients were employed there to their manifest advantage. No one could go 
into these places and see the patients working without feeling that some day or 
other they would have an accident. He thought it would be prejudicial to the 
interests of the insane to have an inquiry into these, because it would make them 
less inclined to run risks for the patients’ good. He asked if there was 
any possibility of getting legal opinion to bear on the Procurator Fiscals, so 
as to exclude the insane from the operation of this Act. Everything that tended 
to make the superintendent of an asylum fearful about giving his patients liberty, 
and that made him hesitate to give certain patients the benefit of the doubt, would 
be distinctly bad; and he felt sure that had there been fatal accidents inquiries 
and coroners’ inquests in Scotland they never would have had the open doors and 
that amount of liberty which he believed distinguished them in Scotland from their 
brethren over the border. 

Dr. McDowall said that when he first went to England he went in terror of the 
coroner, but he had lived long enough there to feel that it was a good thing to have 
public inquiry. He always taught his staff to perform their duties with a sense of 
responsibility to the best of their ability and with pure motives. If they did that, 
then they need not be afraid of a coroner or any one else. He had these inquiries 
morethan once in the Northumberland Asylum, and never had reason to com¬ 
plain of the treatment received from a coroner or jury. He was satisfied in his 
own mind that the feeling through the whole staff that they might be at any time 
called upon in a public court to answer for their conduct had a most wholesome 
effect. He reminded them that there is inquiry into the death of prisoners, 
although they received no wages. He was sure that Scottish superintendents had 
nothing to fear in regard to public inquiry into any accident. 

The President said that inquiries into prisoners’ deaths were inquiries under a 
special Act, but that the question now before them was whether it was desirable that 
public inquiry should be held in regard to fatal accidents in asylums. If that 
were desirable they might let the matter drop ; if not, they might in the meantime 
ask Dr. Clouston to obtain legal opinion as to how far this Act affects the insane 
in asylums in the manner he had kindly indicated. 

The meeting agreed to the latter alternative and the adjournment of the discus¬ 
sion till next spring. 


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THE UTERUS IN THE INSANE. 


23 


A Conmiunication on the Macroscopical and Microscopical 
Appearances of the Uterus and its Appendages in the 
Insane . By J. G. Gordon-Munn, M.D., F.R.S.E. 

Whilst it is the object of this paper to deal with the subject 
in the main as limited by the title, it is well that some 
consideration be given to the general literature bearing upon 
the relations between diseased conditions of the uterus and 
appendages and diseased conditions of the mind. 

It has long been held that a decided relation does exist 
between pathological conditions of the sexual apparatus in 
women and insanity. So far, indeed, has this been carried 
beyond the limits of sound judgment, that certain writers have 
ventured to propose excision of certain portions of the genital 
organs as a remedy for morbid conditions of the brain : one 
such instance of this literature is a pamphlet by Dr. J. Baker 
Brown, published in 1866, recommending “ Clitoridectomy, a 
cure for certain forms of insanity.” In many instances it might 
appear as rational, in view of the great advance in brain 
surgery, to excise certain portions of that organ which are 
believed to have a relation to the sexual apparatus for morbid 
conditions of the latter. It has to be said, however, that the 
operative removal of the overies and tubes on both sides 
produces in many cases a distinctive altered mental status, as 
much a sequel to the operative procedure as is the altered 
mental condition following removal of the thyroid gland. 
Albeit the train of symptoms following the two operations 
presents little, if any, analogy, and so far as it is at present 
known they afford different fields of speculation as to their 
cause. 

Such publications as the one above referred to have in no 
way checked sound clinical and other observations which go to 
establish the relations between sexual and mental pathology. 
Going so far back as 1819, we find that Dr. Robert Gooch, in 
his observations on puerperal insanity, dwells ably on the relation 
of organic derangement of the uterus to insanity. Drs. C. and 
F. Fox, in the 4 Report of Brislington House* for 1864, assert 
that masturbation, which may be dependent in many instances 
on a sexually pathological condition, may be in turn a cause 



24 the uterus in the insane, [Jan., 

of insanity, and not only a symptom of an unsound mental 
condition. 

In 1869 Dr. Louis Mayer, in his ‘Die Beziehungen der 
Krankhaften Zustande und Vorgange in den Sexual Organen 
des Weibes zu Geistessterungen/ comments on the altered 
mental condition during pregnancy, menstrual onset, and meno¬ 
pause, amenorrhcea, uterine congestion, vaginismus, and other 
sensitive conditions of the external genitals, pruritus vulvae, 
dyspareunia, conditions of tumours of sexual organs, procidentia 
uteri, chronic endometritis, cancer of cervix, and malpositions 
of the uterus. These in cases cited he relates to hysteria, 
somnambulism, folie circulaire, erotic mania, melancholia, hypo¬ 
chondriasis, &c. 

Pozzi, in his ‘Gynaecology/ 1891, says, “It is certain that 
any genital disease in a woman predisposed to hysteria will 
produce a developement of that neurosis. Dr. G. R. Shepherd, 
in the ‘Yale Medical Journal/ 1894-5, contributes an article 
on ‘ Uterine Mal-positions and Diseases as a Cause of In¬ 
sanity.* And H. A. Tomlinson in 1893, ‘The Association - 
of Visceral Disease with Insanity/ also deals, though not so 
directly, with the subject under consideration. 

In 1897, too, this subject was dealt with at the British 
Medical Association meeting at Montreal by Drs. Roh£, Hobbs, 
Russell, and Clark. In the discussion of this subject, as might 
have been expected, the members of the section showed but 
little sympathy with the practice of Drs. Roh£ and Hobbs. Dr. 
Alexander adduced strong evidence against the statements in 
favour of the high percentage of disease when he said that out 
of the thousands of post-mortem examinations at which he had 
assisted at Han well, but very few showed evidence of pelvic 
disease. 

Such is a short summary of the literature on the subject. 
Amongst the larger general treatises on the diseases of women, 
Dr. J. C. Skene, of New York, devotes a chapter to ‘ Gynaecology 
as related to Insanity in Women.* He states that insanity is 
often caused by disease of the procreative organs ; that an 
acute disease of the ovary or uterus, or displacement of either, 
is sufficient to cause mental derangement, which will subside 
when the disease of the pelvic organs is relieved ; that there is, 
indeed, amongst women a distinct class of insane cases where 
the aetiology must be studied from the point of view of 


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BY J. G. GORDON-MUNN, M.D. 


1899.] 


25 


diseased sexual organs. The derangement in such cases may 
be functional, or, with less hopeful prognoses, organic. 

Amongst general considerations he remarks upon the diffi¬ 
culties to be encountered in this field of observation, mentioning 
amongst others the comparatively little help obtained by reference 
to the case-books of the larger asylums. 

It would appear that this must be the case for some time, 
and coming more particularly to the subject-matter of the 
paper, it has been deemed well to place on record a series of 
cases the insane conditions of which being first summarised, 
full consideration is then given to the macroscopic and micro¬ 
scopic post-mortem appearances of the uterus and its adnexa. 

Thereafter is appended a brief summary of these points, 
which would appear to be the more important in regard to (< a ) 
the Gynaecology of the Insane, ( b ) General Gynaecology. 

In 246 consecutive post-mortem examination at the London 
County Asylum at Cane Hill, I found only 33 instances of 
pelvic disease, or a percentage of 13*8. 


Series of Cases . 

1. S. R. H—, aet. 62. Widow, three children. Chronic 
mania of several years’ duration ; noisy, excitable, troublesome, 
and delusional. 

Post-mortem. Naked-eye Appearances. —(1) Right append¬ 
ages : tube 3^ inches, normal. Mesosalpinx normal ; paro¬ 
varium very indistinct; one small simple broad ligament cyst 
projecting posteriorly. Right ovary : atrophied 1 inch x § ; 
tissue pale in section, and in an atrophied follicle there is a 
dark-stained detachable lining membrane. (2) Left append¬ 
ages : tube 4 inches, normal. Mesosalpinx normal ; parovarium 
very indistinct ; two minute simple broad ligament cysts pro¬ 
jecting posteriorly, also one projecting anteriorly—marble 
size—contained straw-coloured albuminous fluid. Ovary 
atrophied, ij x J inch, indistinct traces of Graafian follicles. 
Tissue pale. (3) Uterus : external measurement 2x2 inches ; 
senile atrophic changes marked, small fibro-myomatous nodule, 
pea size, on the middle of posterior wall. 

Microscopic Appearances. —Ovary x 90 : tunica albuginea 
thick ; no ova near surface ; follicles are crowded irregularly 
here and there, and what appears to be dense fibrous 





26 THE UTERUS IN THE INSANE, [Jan., 

tissue surrounds them. x 690: vessel walls thickened, many 
of them have their lumens obliterated. Uterus x 90 : large 
thick-walled vascular spaces seen, and the atrophied remains 
of utricular glands ; vessel walls generally are thickened, x 690: 
glandular epithelium small ; fibrous tissue seen in excess in the 
vessel walls. 

2. A. S—, aet. 33. No occupation. Single. Predisposing 
cause, heredity ; exciting, alcohol. Father and two sisters died 
of drink. Admitted December 3rd, 1895. Died January 10th, 
1896. Mania a Potu. Heard voices, &c. Feeble, very rest¬ 
less, noisy, and sleepless ; dirty and destructive in habits. Had 
deep corneal ulceration and conjunctivitis. 

Post-morte?n .—Thin, poorly nourished ; oedema of fine brain 
membranes ; lateral ventricles dilated ; liver fibrosed, 60 oz.; 
numerous gall-stones ; kidneys congested ; some congestion of 
the external os. (1) Right appendages : tube 4 inches, normal. 
Mesosalpinx : parovarium very well defined. Ovary : ij x 1 
inch. On section well-defined marginal follicles ; stroma 
appears somewhat haemorrhagic. On section black pigmented 
scar. (2) Left appendages: tube 5 inches, normal ; paro¬ 
varium small but distinct. Ovary : replaced by a unilocular 
cyst of large orange size and shape, containing clear straw- 
coloured fluid ; cyst has a smooth lining, and its walls are 
thicker towards the hilar portion, traces of ovarian tissue 
being recognised here; no superficial adhesion sites. (3) 
Uterus: externally 2 \ x 2 inches, mucosa smooth, shows some 
black pigment near the orifices of Fallopian tubes. 

Microscopic Appearances .—Ovary x 90 ; tunica albuginea 
dense ; there are many blood-filled follicles irregularly accu¬ 
mulated. There are many also which are not blood-filled, but 
those of any size are irregular in shape. Very few of the 
follicles contain healthy ova. There are also seen large stromal 
ecchymoses. x 690 : whilst the albuginea is dense there is no 
marked tendency to the formation of fibrous tissue. Round the 
follicles blood-vessel walls are well marked. Uterus x 90 : 
vessel walls are seen to contain a considerable amount of 
muscular tissue. Cyst wall x 90 : composed mainly of wavy 
bundles of fibrous tissue. There is considerable differentiation 
into layers ; one or two large blood-vessels are seen. x 690 : 
there is also some muscular tissue in the wall, the epithelial 
lining on the inner surface of the walls is not distinctly seen. 


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1899.] 


BY J. G. GORDON-MUNN, M.D. 27 

3. A. G —, set. 22. Single. Servant. Suffering from mania 
passing into dementia ; had syphilis. 

Post-mortem . Naked-eye appearances .—(1) Right appendages : 
tube—4 inches, small fimbriated end much congested. Meso¬ 
salpinx : veins congested ; parovarium indistinct. Ovary: 
elongated though small—x i inch ; superficially pale 
and smooth. On section a few small follicles seen ; stroma 
haemorrhagic. (2) Left appendages: tube 34 inches; no 
fimbrial congestion. Mesosalpinx: veins less congested ; 
parovarium distinct. Ovary ij x f inch, smooth and pale 
superficially, on section considerably paler than right ovary. 
(3) Uterus: 2 \ x ij externally. On section arbor vitae well 
marked ; mucosa of corpus smooth and non-haemorrhagic. 

Microscopic Appearances . —Right tube (ampulla) x 90 : walls 
thickened ; blood-vessels much engorged, many ecchymoses, 
mucosa irregular and imperfect. x 690 : mucosal fronds show 
marked leucocytosis, columnar ciliated epithelium is retained 
over many of them ; irregular-shaped cells are seen in the 
lumen between the fronds. Right ovary x 90 : no large 
follicles are seen near the surface, there are many at the deeper 
levels ; the vessels are numerous and engorged, and there is 
some stromal ecchymosis. x 690 : many of the young follicles 
are perfectly formed, some of the older ones are represented by 
blood-filled spaces. Uterus x 90 : walls appear normal ; the 
mucosa is irregular. x 690 : catarrhal changes are seen in the 
uterine glands. 

4. A. P—, aet. 79. Suffering from chronic mania ; duration 
thirty years. Married, and had a family. 

Post-mortem . Naked-eye Appearances. —(1) Right append¬ 
ages : tube 3 inches ; fimbriae attenuated, tube slightly 
thickened at mid-portion ; ovarian fimbriae tense and thickened. 
Mesosalpinx : from the anterior surface close to hilum of ovary 
there springs a glove-finger shaped cyst i£ inches long by { 
inch wide ; there is fat in the composition of its walls ; near the 
extremity it contains turbid yellow watery fluid ; parovarium 
very faint in outline ; ovarian sac well marked. Ovary : size 
normal ; irregular nodulated surface, due to projection of small 
cysts. On section the tissue is seen to be almost wholly cystic ; 
the cysts are from shot to pea size, and contain yellow viscid 
material. Left appendages : tube 4^ inches, normal. Meso¬ 
salpinx : healthy ; parovarium outlines very faint. Ovary 










28 


THE UTERUS IN THE INSANE, 


[Jan., 


irregularly rounded in shape, I x 4 inch ; surface irregularly 
nodulated as on opposite side. On section the organ is wholly 
cystic except in its upper outer third, where there is a densely 
calcified corpus luteum of marble size. Contents of cysts are 
straw-coloured watery fluid. Uterus: senile changes. On 
section a turbid, yellow, watery fluid is seen in small quantity 
in cavity of uterus itself. In its mucosa the mouths of the 
glands are well seen, and a similar fluid is expressible from 
them. The cervical canal is blocked by an abundant muco¬ 
purulent secretion like white of egg. 

Microscopic character of fluids of uterine cavity proper : epi¬ 
thelial cells in various stages of fatty degeneration ; no mucous 
globules. 

Secretion of cervical canal : mucous globules, pus cells, 
epithelial cells in various stages of fatty degeneration. The os 
internum is very narrow ; the cervical canal is much widened, 
and seemingly excavated by some process which has produced 
the muco-pus described (see microscopic section of cervix). 

Microscopic Appearances .—Right tube x 90 : muscular and 
fibrous factors of the wall thickened ; mucosal plicae simplified, 
x 690 : epithelium of mucosa is shed in many parts ; leuco- 
cytosis is at parts marked ; many of the crypts are full of 
small, closely packed, irregularly shaped cells. Uterus corpus 
x 90 : glands not well seen. x 690 : proliferation of con¬ 
nective tissue of the wall, also the cellular structure of the 
glands is not well seen in the specimen. Right ovary x 90 : 
one or two large blood-filled follicles. x 690 : the membrana 
granulosa of the blood-filled follicles is proliferative ; blood¬ 
vessels well formed. Corpora-luteal remains partially organised 
are seen. The excavation of the cervix is surrounded by firm 
fibro-muscular tissue and lined by irregularly distributed and 
proliferative cylindrical epithelium. 

5. E. D—, act. 35. Congenital imbecile. Very excited, 
noisy, destructive, and troublesome. 

Post-mortem . Naked-eye Appearances .—(1) Right append¬ 
ages: tube 34 inches, normal; within 4 inch of fimbriated 
extremity there springs from the upper surface of the tubes a 
slender stalk of 4 inch in length ; this stalk terminates in a 
rosette of minute fimbriae, and from its centre another and still 
finer stalks springs $ inch in length, terminating in a unilocular 
cyst of pea size containing albuminous fluid (pedunculated 


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1899O 


BY J. G. GORDON-MUNN, M.D. 


29 


hydatid). Mesosalpinx vascular ; parovarium small. Ovary 
elongated, if x | inch ; surface smooth generally ; on section 
a few marginal follicles are seen. (2) Left appendages : tube 
short, 24 inches, somewhat thicker than the right. Meso¬ 
salpinx thin ; parovarium very small, not so vascular, but from 
its base and from anterior surface of mesosalpinx a very 
attenuated thread-like stalk spring 1 \ inches in length, termi¬ 
nating in a hydatid as on right side. Ovarian sac marked. 
Ovary more rounded, surface not so smooth as right ; a few 
marginal follicles seen on section. Ovarian ligament short and 
thick. Uterus 2 x 14 inches externally; on section some 
watery fluid in cavity of uterus proper. Mucoid secretion in 
cervical canal. 

Microscopic Appearances .—Tube (left) near ampulla x 90 : 
the factors of the wall, including the complicated mucosal folds, 
are well formed. The epithelium of the last is in the main 
perfect. Right ovary x 90. Follicles are abundant, though 
small and accumulated in clusters. Some of the clusters are 
isolated from their neighbours by comparatively less cellular 
tissue. The blood-vessel walls are well marked. Here and 
there patches irregularly distributed of comparatively non- 
cellular tissue are seen. In the interval between the nuclei of 
these patches no definite structure is traceable. Uterus x 90 : 
the mucosal and other coats are well formed. The epithelium 
of the glands is normal. 

6. E. H—, set. 61. Single. Domestic, suffering from 
melancholia which followed influenza. Refused food and very 
depressed. 

Post-mortem . Naked-eye Appearances . —Right appendages : 
tube 6 inches ; thin, fimbriated end well developed. Meso¬ 
salpinx healthy ; parovarium faint. Ovary elongated, 2 x J inch ; 
surface smooth, on section inner third is pale and atrophied. 
Left appendages : tube 3 inches ; fimbriae well marked, a few 
cysts similar to opposite side. Mesosalpinx : a small peduncu¬ 
lated hydatid springs from the anterior surface of outer portion. 
Parovarium more distinct than right. Ovary elongated, 

I ^ x \ inch, surface smooth ; on section tissue pale, but not so 
pale as opposite side. Uterus 2J x inches, of fair bulk ; on 
section a glairy white yellow secretion occupies cavity of cervix, 
and a more watery turbid fluid is present in small quantity in 
corpus. 




30 THE UTERUS IN THE INSANE, [Jan., 

Microscopic Appearances .—Uterus x 90 : the glands show 
decided catarrhal change, and there is a considerable amount of 
leucocytosis in the mucosal interstitial tissue. In the muscular 
layers is some endarteritis obliterans. Tube x 90. The 
vessels are engorged, and their lumens in some cases distended. 
The type of tubal epithelium is degraded into cubical epithelium 
at many parts. The ciliae are at many parts with difficulty 
detected. Columnar epithelium is, however, seen in many 
parts, though frequently there is a double layer, the subjacent 
layer being of irregular formation. At other parts there is but 
a single layer of low columnar epithelium, the regularity of 
which is interrupted by subjacent oval and rounded large cells, 
apparently of inflammatory origin. Ovary : vessel walls thick¬ 
ened ; several degenerated follicles are seen, i. e. degenerated in 
the direction of being filled with inflammatory products. No 
follicles of typical healthy structure are detected. Large areas 
of structureless material slightly stained, and interpolated 
between the tissues of the organ, are present. 

7. H. C—, aet. 71. Suffering from senile dementia. Widow. 
Has had paralytic attacks for twelve years. Epithelioma of 
vulva. Right appendages : tube 2§ inches; several small 
simple broad ligament cysts, small shot size, in region of 
ampulla. Mesosalpinx : parovarium faint, healthy ; there is a 
small pedunculated hydatid from anterior outer portion. Ovary 
elongated, 1 § cystic at outer end, measuring here J inch trans¬ 
versely. On section the ovarian tissue appears to extend for 
some distance into the ovarian ligament. The cystic condition 
at the outer part of the ovary is unilocular, and appears to have 
been the result of distension of a follicle. The cystic fluid is 
dear, watery, and straw-coloured. Left appendages : tube 3 
inches, appears somewhat contorted and elongated towards the 
outer end, and somewhat thickened. Mesosalpinx : parovarium 
indistinct, a few small cysts towards the outer portion ; a small 
pedunculated hydatid springs from the anterior and outer 
portion. Ovary: small and atrophied, surface smooth, 1 x £ 
inch; ovarian tissue does not appear to extend to same degree 
into ovarian ligament as on opposite side Uterus 2 \ x 2 
inches. On section, cervical canal contains starch-like sub¬ 
stance. Uterine cavity contains blood-clot and sanious debris ; 
the mucosa is deeply ecchymosed generally. 

Microscopic Appearances .—Ovary x 90 : many of the vessels 


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1899] 


BY J. G. GORDON-MUNN, M.D. 


31 


are engorged, and in some cases there is parietal thickening 
amounting in one or two instances to luminal obliteration. 
Some partially obliterated follicles of atypical structure are 
accumulated in irregular groups. The structure of the organ 
in some places is suggestive of myxomatous change. Uterus 
x 90 : mucosa is destroyed in many places by ultra-glandular 
and interstitial blood effusion, whilst the muscular coat shows 
degeneration from the same cause, and also there is some 
degree of leucocytosis in the portion of the uterine wall. 

8. M. A. F—, act. 48. Widow. Suffering from melancholia 
and dementia. Suicidal, alcoholic, masturbates, hypertrophy of 
nymphae. 

Post-mortem . Naked-eye Appearances .—Right appendages : 
tube 34 inches, thickened considerably in its outer third and 
lengthened ; its mucosa is also here hypertrophied. On the 
dorsum of outer part of tube within £ inch of fimbriated end a 
fimbriated stalk springs. The length of the latter is 1 inch. 
Fimbriae round the abdominal ostium are well marked. Meso¬ 
salpinx normal; parovarium distinct. Ovary of normal size 
and structure ; a recent ruptured follicle is present at this outer 
pole. Left appendages: tube 4 inches; also somewhat 
thickened in its outer third, though not to the same extent as 
opposite side. Mesosalpinx normal ; parovarium very distinct. 
Ovary normal size and structure. Both ovaries on section 
show network-like mottling of red and white, the red appearing 
to map off in mesh-like fashion the enclosed white areas. 
Uterus = 2 \ x i£ inches. At right upper posterior portion of 
fundus there are three pedunculated fibroids of pea size. The 
pedicles are less than £ inch in length. On section nothing ab¬ 
normal is visible. Arbor vitse in cervical canal is well marked. 

Microscopic Appearances .—Right tube x 90 : a large portion 
of the tubal structure is destroyed by haemorrhage. Catarrhal 
changes and leucocytosis are present in the mucosal ridges. 
Uterus x 90: many of the glands are imperfect in structure, 
and there is no noteworthy change in the muscular coats. 
Ovary x 90 : tunica albuginea is well marked, and its com¬ 
ponent structures are delicately outlined. Towards the central 
portion of the organ some large spaces are visible, filled with a 
structureless material (corpora lutea ?). Follicles are present in 
some number, some well defined, the majority irregular in outline 
and structureless in contents. 





































32 THE UTERUS IN THE INSANE, [Jan., 

9. A. D—, act. 30. . Married. Suffering from chronic 
melancholia. Suicidal, alcoholic, of immoral habits, been living 
with a man, no children, syphilitic. Had occasional severe fits, 
nature uncertain, always abusive and noisy. 

Post-mortem . Naked-eye Appearances .—Right appendages : 
tube 5 inches ; general size normal ; fimbriae not well marked. 
Mesosalpinx broad. The ovarian fimbriae 2 \ inches long, 
the proximal half of it cord-like, and shows no groove ; paro¬ 
varian tubes faintly marked. Ovary bulky and soft, surface 
somewhat smooth, ii x 1 inch. On section the tissue is 
seen to be soft and oedematous, and there are three distended 
follicles of small marble size: at the margin these contain clear 
straw-coloured fluid ; corpus-luteal remains are seen. Left 
appendages are irregularly matted as a whole by the inflam¬ 
matory process. Tube 4 inches, contorted, somewhat thick¬ 
ened, and hard. Fimbriated end of irregular shape. The 
abdominal ostium is much distended, admitting a lead pencil. 
The os has evidently been separated from an adjacent viscus 
in the process of post-mortem manipulation. Mesosalpinx 
thickened and partially obliterated ; parovarium not recog¬ 
nisable. Ovary is matted to the broad ligament, and has been 
mutilated by post-mortem manipulation. It appears to have 
been of somewhat bulky dimensions ; its tissue is firmer than 
that of the other side, and on section three small white points 
of shot size are seen there, still harder than the surrounding 
tissue, and appear to be exsanguine. Uterus = 2J x if inches. 
On section nothing abnormal is detected. 

Microscopic Appearances x 90 and x 690.—Nothing special 
to note. 

10. C. H—, ret. 61. Single, suffering from mania with 
epilepsy. Alcoholic and immoral, three months insane. 

Post-mortem . Naked-eye Appearances .—(1) Right append¬ 
ages : tube 3^ inches, somewhat thickened ; an inch from the 
abdominal ostium proper there is an accessory ostium with 
well-developed fimbriae, and the distal and proximal portions of 
the tube involved are represented by two distinct apertures. 
Mesosalpinx normal in size. Ovary normal size and contour; 
on section no corpus luteum is seen. (2) Left appendages : 
tube 4 inches ; outer inch is twice thickened and contorted (see 
microscopic examination). Mesosalpinx shows a small intra¬ 
ligamentous cyst of pea size and shape ; contents are albu- 


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1899.] 


BY J. GORDON-MUNN, M.D. 


33 


minous fluid, and the cyst is evidently developed from one of 
the vertical tubules of the parovarium. Ovary normal size 
and contour ; on section luteal remains are seen, but no ripe 
follicles. (3) Uterus 3x2 inches ; appears normal. 

Microscopic Appearances . —Left ovary x 90 : tunica albu¬ 
ginea distinct ; remains of follicles are seen deeply set in the 
organ ; vessel walls are thickened. Left tube x 90 : blood-vessels 
enlarged and engorged ; mucosal fronds are considerably multi¬ 
plied, and their epithelium is irregular and in many places being 
shed ; the connective tissue of fronds is also thickened, and 
there is leucocytosis. Uterus x 90 : mucosal and other layers 
appear normal. 

11. F. A. E—, set. 28. Single. Suffering from melancholia. 
Insane for one year. 

Post-tnortem. Naked-eye Appearances . — (1) Right append¬ 
ages : tube much elongated ; the outer two inches are trans¬ 
formed into a cyst of Tangerine size and shape, nature of fluid 
it contained not ascertained ; within the cyst the fimbriae of the 
proximal portion of the tube are seen spreading out, and 
gradually disappearing over the inner surface of the attenuated 
walls. There are no inflammatory adhesion sites on the tube 
or cysts, and during life it would seem to have been a pedun¬ 
culated floating cyst; two hydatids spring from the anterior 
inner margin of the cyst. Mesosalpinx: parovarium is un¬ 
usually well marked, and has no relation whatever to the cyst. 
Ovary } x J inch, and on section shows a ripe follicle of shot 
size. (2) Left appendages have been mutilated in removal. 
Tube portion present 2 \ inches in length, and is thrice 
thickened ; the outer portion of the tube is not distinctly trace¬ 
able, but appears to terminate in a condition analogous to that 
affecting the other side ; the walls of the cyst are much thicker, 
however. Ovary is not traceable. (3) Uterus 2x1 inch ; 
walls thinned ; the utero-vesical pouch has been obliterated by 
the mutual inflammatory adhesion of the peritoneum on the 
anterior surface of uterus, and that on the posterior surface of 
bladder ; mucosa is unhealthy, is thinned and anaemic. 

Microscopic Appearances .—Right ovary x 90 : the tunica 
albuginea is thickened ; follicles irregularly accumulated and of 
irregular shape ; membrana granulosum is irregularly multiplied ; 
so irregular are some of the follicles in shape, and so irregular 
their aggregation, that in these cases where the membrana 

XLV. 3 





34 the uterus in the insane, [Jan., 

granulosum has multiplied so far as to fill the follicles with 
compressed cell elements the structure has the appearance of 
a scirrhous cancer. Uterus x 90 : the elements of the walls 
seem thickened and are hypertrophied, and do not stain well. 
Left tube x 90 : all the elements of the wall are infiltrated 
with inflammatory exudations, and in the cross-section of the 
tube the remnants of the lumens appear as some ten or so 
irregularly shaped cavities, lined by disorganised epithelium ; 
the muscular layers are unrecognisable. 

12. R. J. B—, aet. 68. Widow. Suffering from senile 
dementia ; duration some years. 

Post-mortem . Naked-eye Appearances . — (1) Right append¬ 
ages : tube 3 inches ; appears normal, slender; a small tuft 
of fimbriae on a slender stalk springs from a point on the upper 
surface of the tube within £ inch from the ostium ; calibre and 
structure of the tube appear normal. Mesosalpinx : there is a 
fairly well-marked ovarian sac ; parovarium distinct. Ovary 
1 £ x | inch ; structure and configuration appear normal ; on 
section some ripe marginal follicles are seen, and the remains 
of a corpus luteum. Left appendages : tube 4 inches, normal. 
Mesosalpinx: ovarian sac not so marked, nor is the parovarium 
so distinct as on the right side. Ovary 1 £ x £ inch ; structure 
and configuration appear normal, and on section one or two 
small marginal follicles are seen. Uterus if x 1 £ inches ; plug 
of clear mucus in cervix ; mucosa pale. 

Microscopic Appearances .—Uterus x 90 : tubular structure 
of mucosa atrophied, vessel walls thick, muscular layers not 
easily differentiable from each other. Ovary x 90 : “germinal” 
layer is still well represented, in parts being well seen in the 
dips of the simple surface corrugations ; there are no follicle 
remnants near the surface of the organ, but deeper, many of 
them are irregularly accumulated, some few showing the kidney 
shape noted in some previous sections. 

13. A. R—, aet 75. Widow. Suffering from chronic mania 
for eleven years. 

Post-mortem . Naked-eye Appearances . —(1) Right append¬ 
ages : tube 3 inches, of small calibre. Mesosalpinx : ovarian 
sac well marked ; parovarium small; in the centre of the meso¬ 
salpinx there is a small nodule of pea size within the layers of 
the broad ligament ; this nodule is composed of hard blood- 


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1899] 


BY J. GORDON-MUNN, M.D. 


35 


clot, and a calcified rounded nodule of gun-shot size ; this con¬ 
dition is probably the sequel of a simple broad ligament cyst. 
Right ovary is small, and contains two corpora lutea. (2) Right 
appendages : tube 4 inches, also of small calibre. Mesosalpinx: 
ovarian sac well marked ; parovarium small, and situate as on 
the other side in the outer angle of the sac ; a small nodule is 
present of fibrous tenure and pea size in the peritoneum imme¬ 
diately anterior to the ovarian fimbria. Left ovary very small, 
elliptical in shape, and is comparatively smooth, and contains 
two corpora lutea. (3) Uterus 3 x ij inches: somewhat thin- 
walled ; mucosa of corpus is soft and haemorrhagic, that of 
cervix is not so soft, and is not haemorrhagic. 

Microscopic Appearances . —Uterus x 90 : in the outer half 
of the wall the vessel lumina are numerous, and their walls are 
extraordinarily thickened, enclosing little if any blood ; in the 
inner half of the wall the tissue is mainly composed of a net¬ 
work of engorged blood-spaces, though here too at many points 
the vessels are much thickened, thickening being apparently due 
in the main to an inflammatory exudation amongst the wall 
elements. There is marked leucocytosis at parts ; little if any 
typical gland structure is present. 

14. M. A. A—, aet. 68. Widow. Suffering from chronic 
mania for ten years, noisy, delusional, and abusive. 

Post-mortem . Naked-eye Appearances . — (1) Right append¬ 
ages : tube 2 \ inches, contorted within the peritoneum ; fim¬ 
briae abundant. Mesosalpinx : thickened, and shows a small 
ovarian sac ; parovarium not recognisable. The ovary is very 
small, i x | inch, and has a perfectly smooth surface ; on 
section the tissue appears practically barren. (2) Left append¬ 
ages : tube 3 inches ; arched from adhesion and contraction of 
ovary ; appears normal ; fimbriae free and luxuriant. Meso¬ 
salpinx also somewhat thickened. Ovary is adherent by its 
upper surface in the ovarian sac ; parovarium is indistinct ; 
ovary is also small, smooth surface, and apparently barren 
tissue. (3) Uterus 2f x ij inches; there is a small fibroid 
subperitoneal nodule, partially pedunculated at the upper 
posterior part of fundus ; on section this nodule is seen to be 
partially calcified ; the uterine cavity is filled with blood, though 
not distended with blood-clot ; mucosa is generally smooth ; the 
small pits of gland mouths are evident. There is, however, a 



36 THE UTERUS IN THE INSANE, [Jan., 

roughened portion of mucosa at the middle of posterior wall ; 
this may possibly account for the haemorrhage : the microscopic 
section of corpus is from this region. 

Microscopic Appearances .—Uterus x 90 : nothing unusual is 
noticeable in the muscular coat. Superficial ulceration is 
noticeable, with thickening of the portion which might repre¬ 
sent the edge of the ulcer. Underneath the ulcerated portion 
the glandular arrangement is very irregular and contorted. 
The glands to the side of the ulceration are in the main 
healthy, their lining epithelium being tall, luxuriant, ciliated 
epithelium, with slight catarrhal changes here and there. In 
other glands, again, some large round-cells are noticeable, 
breaking up the regularity of the lining epithelium. Tracts of 
submucosal haemorrhage are noticeable here and there. Ovary 
x 90 (apparently barren to naked eye) : the sites of atrophied 
follicles are readily seen ; an ovum, however, is detected in the 
centre of an irregularly shaped follicle at some distance from 
the surface of the organ ; it is surrounded by an undifferentiated 
material filling the remainder of the follicle. 

15. R. S—, married. Suffered from chronic mania for some 
years past. 

Post-mortem . Naked-eye Appearances . — (1) Right append¬ 
ages : tube 4 inches, arched round the ovary in its outer half, 
its fimbrial end being adherent to that organ ; its outer end is 
also somewhat thickened. Mesosalpinx partially adherent to 
ovary. On dissection the parovarium is faintly seen. Ovary 
superficially matted on both surfaces of broad ligament. On 
section irregular aggregations of small follicles are observable. 
(2) Left appendages : tube 34 inches, of very fine calibre, outer 
end somewhat thickened and fimbriae agglutinated. Meso¬ 
salpinx : thin, parovarium barely seen. Ovary smooth and 
atrophied, x £ inch. Uterus 2j x inches; walls thinned; 

mucosa of corpus is softened, breaking down. That lining the 
anterior wall is in a softened polypoid condition, one of the 
polypi being the size of a pea. The structure to the naked eye 
is suggestive of an adenomatous process. This polypus and 
the portion of the uterine wall from which it springs are re¬ 
served for microscopic examination. 

Microscopic Appearances .—Right tube x 90 : mucosal fronds 
are much thickened, inflammatorily infiltrated and very vascular ; 


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1899 -] 


BY J. GORDON-MUNN, M.D. 


37 


at some few points columnar epithelium is retained ; in the main, 
however, it is shed, and an inflammatory exudation occupies the 
recesses of the mucosa. Mesosalpinx is also much infiltrated 
with inflammatory matter. Uterus x 90 (cystic pus of mucosa): 
subjacent to the polypus and also at the side the uterine glands 
are dilated, and filled in some instances with structureless effu¬ 
sion. The unilocular cystic polypus itself (see naked-eye 
examination) appears to be but an exaggeration of the condi¬ 
tion in one or two adjacent glands, their proximate walls 
breaking down to form this comparatively large cavity. The 
lining epithelium is one, two, or three layered, and composed 
for the most part of cells of a degraded columnar type. The 
wall of the cyst is very vascular. 

16. A. H—, set. 60. Suffering from chronic mania ; dura¬ 
tion some years. 

Post-mortem . Naked-eye Appearances, — (1) Right append¬ 
ages : tube 5 inches, and appears normal. Mesosalpinx shows 
some intra-ligamentous haemorrhage towards the hilum of ovary; 
parovarium very faint. Ovary atrophied, smooth surface, 1 £ x § 
inches ; the ovarian tissue extends for i inch into the ligament. 
These are apparently derived from the tunica albuginea. (2) 
Left appendages : tube 4 inches, somewhat thickened at the 
ampullary portion, and its lumen is somewhat patent on section. 
Mesosalpinx: there is a well-marked ovarian sac, and, as 
appears to be general in these cases, the parovarium is found 
towards the outer angle of sac. The ovarian fimbria of the 
tube joins the ovary on its posterior border at the junction of 
its outer and middle third. It is probable that this ovarian sac 
is caused by inflammatory adhesion involving the posterior 
border of ovary, and a portion of the mesosalpinx above the 
level of the hilum. Ovary : atrophied surface is smooth, 1J x 
£ inch ; as on the other side, though to a less extent, the 
superficial layers of the ovary extend into the round ligament. 
Uterus elongated = 3^ x i£ inches; cervix hypertrophied. 
There is a subserous calcareous nodule (calcified fibroid) in the 
left interior portions of the fundus. On section the tissue of 
the hypertrophied cervix shows considerable pallor. There 
appears to be nothing specially noteworthy in the tissues of 
corpus uteri. 

Microscopic Appearances .—Left tube x 90 : blood-vessels of 




38 THE UTERUS IN THE INSANE, [Jan., 

the walls are numerous and engorged, muscular layers not 
differentiable. The mucosal fronds are thickened irregularly, 
and for the most part wanting in epithelium. Hypertrophied 
cervix. The squamous epithelium of the surface is markedly 
developed. Surface “ pittings ” are present, and the superficial 
layers of the squamous epithelium are traceable round their 
walls ; in one or two instances the overhanging edges of these 
“pits ” meet, and suggest a modeof superficial cyst formation. The 
stratum lucidum of the squamous epithelium is especially well 
marked at some parts. For the rest, the section shows an 
irregular hypertrophy of the ordinary cervical factors. Catarrhal 
changes are present in the mucous glands of the cervix. 

17. I. L—, aet. 70. Single. Chronic mania of considerable 
duration. 

Post-mortem Appearances. — Right appendages : tube 5 
inches, very small in calibre. Mesosalpinx partially usurped 
by a very thin-walled cyst, developed probably from one of the 
parovarial tubules. The cyst is of Tangerine size, and contains 
straw-coloured non-albuminous fluid amounting in quantity to 
some drachms. Ovary 1 x £ inch, smooth on surface and 
pale on section. Left appendages: tube 4 inches, very thin 
except at ampulla, where it is comparatively thicker. Meso¬ 
salpinx somewhat thickened and contracted. Ovary i£ x £ 
inch: elongated, almost cord-like in form ; smooth on surface. 
Uterus 2 x 1 £ inches : a plug of viscid mucus occupies the cer¬ 
vical canal, and a blood-stained less viscid mucoid material 
separates the walls of the corpus. The arbor vitas is well 
marked in the cervical canal (see microscopic section). 

Microscopic Appearances. —Cervix x 90 : some little distance 
beneath the mucous surface irregular areas of haemorrhage are 
seen. 

18. E. O’N—, aet. 39. Single. Suffering from melancholia. 
Duration one year. 

Post-mortem. Naked-eye Appearances. — Right appendages : 
tube 4 inches, and is normal. Mesosalpinx normal ; paro¬ 
varium is distinct, the convoluted character of its tubules 
being well marked. Ovary 1 £ x £ inch. The breadth of the 
ovary increases distally; surface smooth on section. There is 
some mottling seen, due to the presence of dark green yellow 
spots in some of the follicles ; this coloration is doubtless due to 


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1899-] 


BY J. GORDON-MUNN, M.D. 


39 


the deposit of the blood-colouring matter from the haemorrhages 
into the follicles. Left appendages: tube 3^ inches, normal. 
Mesosalpinx congested ; in its outer half is some ecchymosis ; 
there is also some intra-ligamentous blood effusion close to the 
hilum of the ovary ; the ovarian sac is well marked. Left 
ovary 1 x £ inch ; smooth on surface and mottled on section 
in same manner as organ on right side ; the ovarian ligament 
is attached to the inner end of the posterior border at a point 
which appears to cause strain on the mesosalpinx, and a 
“ pitting ” resulting in the formation of the ovarian sac referred 
to. Uterus i£ x 2^ inches; on section nothing noteworthy is 
found. 

Microscopic Appearances .—Uterus x 90 : catarrhal changes 
are present in the mucosa glands of the cervix. Elongated 
ovary x 90 : superficially the tunica albuginea and the connec¬ 
tive tissue of the organ subjacent to this are increased in 
density. Towards the centre of the organ follicles in various 
stages of degeneration are present. In the case of those which 
are almost obliterated concentric arrangement of the tissue 
causing such obliteration is noticeable ; a degenerated ovum is 
seen here and there within these ill-formed follicles. 

Summary A (Special to Insane).—(1) Case 12. Kidney 
shape of atrophied follicles. (2) Comparative anaemia of the 
follicular tissues. (3) Case 8. Peculiar mottled condition of 
the ovary, with hyperaemia and stromal haemorrhage of tubes, 
in notorious masturbator. 

SUMMARY B (General).—(1) Case 11. Chronic salpingitis. 
(2) Case 14 ? Early stage of malignant disease. (3) Case 14. 
A well-formed follicle containing an ovum in the ovary of 
a woman of sixty-eight. (4) Case 1 5. Development of cystic 
polypus from the utricular glands. (5) A. Case 16. Possible 
development of cervical cyst from invagination of the squamous 
epithelium of vaginal portions. (5) B. Case 4. Development 
of cervical cyst with its subsequent suppuration from dilation 
of cervical canal. (6) Average length of right and left tubes. 
In eight cases out of eighteen the right tube is longer than the 
left tube. (7) In senile ovaries the aggregation of thickened 
vessels, apparently in the site of old corpora lutea ; these may 
be readily mistaken for follicles with fibrous change round them. 
(8) In Case 3 (also in Case 9) the immunity from specific change 
in the uterus and appendages in a patient who died from 







































40 


TREATMENT OF INSANITY BY THYROID, [Jan., 


acquired syphilitic disease of the brain. (9) Case 4. Uterine 
stone of marble size, probably from calcification of corpus 
luteum. (10) Case 7. With a condition of vulvar cancer 
nothing more may be noticeable in the condition of the internal 
organs of generation than mucosal hyperemia. (11) Case 12. 
Semblance of the histology of scirrhous cancer in centre of an 
ovary by the multiplication of membrana granulosum in closely 
adjacent follicles, partitioned off from each other by fibrous 
stroma. (12) Hydatids. Pedunculated hydatids spring in 
almost all cases from the anterior outer portion of the meso¬ 
salpinx, and have a close relation to either the parovarium or 
the fimbriated end of the tube. (13) The parovarium is 
appreciably more prominent in the anterior than the posterior 
surface of the mesosalpinx. (14) The adventitious formation 
of the ovarian sac as seen in Cases 5, 13, 14, and 18. The sac 
appears to be due to the mutual inflammatory adhesion between 
the upper outer portions of the ovary and the mesosalpinx close 
upon the parovarium : the ovarian ligament being tense, the 
result is the formation of a deep pocket, which has to be 
distinguished from the congenital non-inflammatory and true 
ovarian sac. 


On the Treatment of Insanity by Thyroid ’ By Jas. 
MlDDLEMASS, M.D., F.R.C.P.E., Medical Superintendent, 
Sunderland Borough Asylum. 

It is now about four years since Drs. Bruce and Macphail 
first published the results of their treatment of cases of insanity 
by thyroid, and since then the new drug has been used very 
extensively in the Royal Edinburgh Asylum. Dr. Bruce has 
published the results of his further experience there, and 
though they are not quite so encouraging as those first carried 
out at Derby they have furnished several remarkable cures, 
and have shown conclusively that in thyroid we have a decided 
addition to our means of treatment. 

This paper contains a short account of the treatment of a 
number of cases in the Edinburgh Asylum which were under 
my more immediate care, and as it may still be considered in 


Digitized by 


Google 



1899.] BY JAS. MIDDLEMASS, M.IX, F.R.C.P.E. 


41 


the experimental stage I have thought it would be of interest 
and utility to add to our knowledge of it, more especially as we 
are met so near the place where it was first tried. 

Before the treatment was commenced each patient was care¬ 
fully examined as to his physical condition. We already know 
that thyroid exercises a most prejudicial influence on phthisical 
processes, acting in fact very much like Koch’s original tuber¬ 
culin. It is therefore necessary to exclude from thyroid treat¬ 
ment all patients who have the slightest evidence of even latent 
phthisis. Organic disease of the heart is also prejudicially 
affected by thyroid, and though it does not altogether prohibit 
its use it necessitates great care in administration. Disorder of 
digestion is also apt to be set up in a few cases, and may 
require special attention. With care in diet it ought to 
be easily overcome. It is well known that, even apart from 
any digestive disturbance which it may cause, thyroid effects a 
pretty rapid loss in weight from increased metabolism, and 
therefore it is distinctly inadvisable to give it to any patient 
who is in an emaciated condition, unless the dosage be small. 
Apart from these exceptions, it may confidently be stated that 
no patient is in danger of being made worse, either physically 
or mentally, by a course of thyroid. 

In the majority of cases the dosage consisted of four tabloids 
of the dried preparation of the gland given thrice daily, this 
being equivalent to 60 grains per diem. This was continued 
for six days as a rule, but it was also given for a longer or 
shorter time in a few cases, as circumstances seemed to indicate 
that this was advisable. The patient was kept in bed during 
the whole time the drug was given, and for some days after¬ 
wards. 

These preliminaries being mentioned, I may now proceed to 
give an account of the results of treatment in individual cases, 
especially of those which showed a remarkable improvement. 
In some this amounted to a practical cure. 

Undoubtedly the most striking case was that of Miss S—. 
It occurred amongst the first of those in whom this treatment 
was tried, and unquestionably it strongly influenced us to per¬ 
severe with it in every case which seemed at all likely to be 
benefited. She was admitted in April, 1895, suffering from 
an attack of excitement which came on during the course of 
adolescent insanity, which had been in existence for two years. 





42 


TREATMENT OF INSANITY BY THYROID, [Jan., 


Mental symptoms first manifested themselves at the age of 
twenty-one, when she became confused and stuporose, with 
occasional attacks of restlessness and impulsiveness. She was 
put in charge of skilled nurses, and subjected to the best con¬ 
ditions and treatment that her doctor and her relatives could 
give her, but apart from slight improvements, followed by 
relapses to her previous mental condition, there was no sub¬ 
stantial advance towards recovery. As already stated, she 
became rather acutely excited, and had to be brought to the 
asylum in consequence. For some time after her admission 
this excitement continued, though it was never very great, and 
when it passed off she was in a condition which appeared to 
indicate that secondary dementia was imminent. All the usual 
means of treatment were had recourse to in an endeavour to 
ward off this undesirable result, but with only partial success. 
She was very apathetic, seldom spoke unless when spoken to, 
and not always even then, and her answers to questions were 
apparently purely reflex. She had little or no initiative, never 
did anything unless told to do so, except go to bed, which she 
was always ready to do, seldom occupied herself, and the work 
she did was always of the simplest kind. Altogether she was 
more like a baby than a full-grown person. Occasionally she 
had little turns of excitement, during which she was inclined to 
strike and to break dishes. These conditions lasted with little 
change for six months, and as there was no prospect of any 
material change it was decided to put her under treatment with 
thyroid. This was done in November, 1895. The dose was 
about 45 grains a day, and this was continued for seven days. 
The physical reaction was quite distinct. The temperature and 
pulse indicated the effects of the drug in a most marked way. 
The temperature rose fully three degrees, and the pulse-rate 
over twenty per minute, and these changes were evident to a 
greater or less degree during the whole time the drug was given, 
and for a day or two longer as well. No mental change was 
visible for the first four days, but on the fifth she appeared to 
be a little restless, more inclined to speak, and more observant 
of what was going on around her. She did not sleep so well 
also. When the fever passed away and she began to go about 
again the improvement was more noticeable. She lost a con¬ 
siderable amount of her apathy, began to talk a little of her 
own accord, and her replies to questions were less mechanical. 


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1899.3 BY JAS. MIDDLEMASS, M.D., F.R.C.P.E. 43. 

She began to take an interest in what was going on, and then 
to ask questions about her surroundings. A few weeks later 
the improvement became still more evident. She seemed to 
have forgotten entirely the events of the previous two and a 
half years, and had to undergo a gradual process of education 
so far as that period of her life was concerned. She had to 
learn the names of persons she had seen daily for six months 
before, but had apparently never noted. Her expression of 
face, which formerly had been vacant or silly, became intelligent 
and alert. Physically there was also an improvement. Her 
weight, which had gone down 9 lbs., now began to increase ; 
her skin became clearer and more healthy-looking, and her hair 
less dry and stiff. She was still somewhat childish in her con¬ 
versation and conduct, but this was evidently undergoing a 
daily improvement. About two months after the treatment 
she had a slight relapse, and became hysterical and emotional,, 
eccentric and foolish ; but this passed off in a week or two, and 
her improvement then went on uninterruptedly. She was dis¬ 
charged in March, 1896. At that time her mother said she 
was more intelligent and brighter than she had ever been in 
her life, and the contrast between her condition then and a year 
before was sufficiently striking to one who had seen her at both 
times. Since then she has kept well, and is now filling her 
place in society like any other sane person. 

Another interesting case of cure, that of Miss J. H. C—, 
presents several features in contrast to that already described. 
She was admitted in September, 1896, suffering from an attack 
of adolescent insanity which had been in progress for a little 
over a year. She was then twenty-six years of age. At the 
onset of the attack she had been depressed and agitated, 
with melancholic delusions, chiefly of a religious character. 
For a time the depression increased, and she got restless and 
excited as well. After some months the depression diminished, 
but the excitement got worse, and she became most trouble¬ 
some, being violent, noisy, destructive, and most difficult to 
manage. She was sent to an asylum, and while there she 
improved so much that at one time she was nearly well. She 
relapsed, however, and after some months, during which she 
became worse than ever, she was transferred to Morning- 
side. She came with a very bad reputation, and quite lived 
up to it. She was usually morose, taciturn, idle, and lazy, 





































44 


TREATMENT OF INSANITY BY THYROID, [Jan., 


but every now and again without any apparent cause she 
became excited, shouted, threw the furniture about, struck, bit, 
and spat upon the nurses if they came near her, and altogether 
was in a typical state of furious mania. At times she was 
somewhat more rational, and would answer questions as if she 
were well pleased with herself. There was seldom any evidence 
of mental depression. Various measures were tried to bring 
about some improvement, but they were only very partially 
successful. She gained some weight and her appetite improved, 
but the attacks of violence and excitement still occurred. In 
April, 1897, it was resolved to give her thyroid. Sixty grains 
were given for six days, but to all appearance there was no 
reaction whatever. The temperature did not rise above 99‘2° F., 
and the pulse remained practically the same. There was, 
however, a considerable physical change induced, as she became 
much thinner and was very weak for a time. Her digestion 
was feeble, and remained so for a week or two. In a month 
her physical state began to mend, and it was only then that 
for the first time signs of some mental change began to be 
apparent. She became quieter, and the attacks of excitement 
less frequent and violent. She was still morose, taciturn, and 
idle, but seemed to be more observant. As time went on the 
improvement also advanced. She began to talk more freely 
and quite rationally, though her memory was not very good, 
and she was depressed and slightly stuporose. She did not 
remember anything of her illness, and took some time to grasp 
her surroundings and the course of events. Thereafter her 
progress continued uninterrupted until she was practically quite 
well. Even at her best, however, it is questionable if she was 
quite the same as she had been before her illness. This is 
hardly to be wondered at considering the severity of her attack 
and the length of time it lasted. She kept well for several 
months, and then she had a slight relapse, becoming sleepless, 
rather restless, and more moody. 

These two cases show in a sufficiently striking manner the 
different ways in which thyroid affects different people, both as 
regards the physical reaction produced and the mental changes 
which led up finally to recovery. It would be both tedious 
and unnecessary to enter so fully as has been done in these 
two cases into the particulars of all the others. It will suffice 
to present the results in tabular form. 


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1899.] 


BY JAS. MIDDLEMASS, M.D., F.R.C.P.E. 


45 


6 

2 

X 

B 

t /5 

£ 

u. 

< 

Mental disease. 

£ 

s 

« 

£ 

Reaction. 

« . 

V CL. 

V 

x ~ 

Highest 
pulse. I 

Result. 

I 

F. 

47 

Suic. melan. 

Grs 

420 

7 

Decided 

994 

128 

Slight improvement. 

2 

F. 

28 Stup. melan. 

540 

9 

11 

1000 

IIO 

Decided improvement. 


F. 

28 

11 

420 

7 

Moderate 

99-8 

112 

Decided improvement. 

3 

M. 

30 

»i 

Exc. melan. 

540 

9 

Slight 

986 

108 

Recovery. 

4 

F. 

43 

600 

10 

Moderate 

99-8 

120 

Decided improvement 

5 

F. 

34 

Del. melan. 

480 

8 


996 

no 

(temporary). 

Slight improvement. 

6 

F. 

24 Stup. melan. 310 

7 Very decided 

100*2 

98 

Recovery. 

l 

M. 

27 

Si. mama 

360 

6 

Slight 

990 

92 

No change. 

8 

M. 

3 i 

Chr. mania 

420 

7 

Moderate 

99*2 

124 

No change. 

9 

p- 

45 Stup. melan. 360 

7 

Slight 

98*8 

120 

Distinct improvement. 

10 

F. 

26 

11 

240 

5 

11 

990 

108 

Distinct improvement 

11 

F. 

2 4 

11 

300 

5 

11 

99*0 

124 

(temporary). 

Slight improvement 

12 

F. 

47 

11 

24O 

4 

Decided 

100*0 

112 

(temporary). 

Slight improvement. 

II 

F. 

49 

»» 

360 

6 

Moderate 

100*0 

112 

Slight improvement. 

II 

F. 

50 


9OO 

60 

None 

Normal 

Decided improvement. 

13 

F. 

21 

ft 

360 

6 

Decided 

100*0 

110 

Slight improvement. 

14 

M. 

27 

„ 1360 

6 

11 

100*0 

116 

No change. 

'5 

M. 

27 

Del. melan. 

360 

6 

Slight 

99 *o 

100 

Slight improvement. 

16 

M. 

28 

11 

540 

9 

99 

99 *o 

104 

Slight improvement. 

F. 

43 

11 

360 

6 

Moderate 

100*0 

112 

Decided improvement. 

17 

F. 

52 

Hyp. melan. 

24O 

4 

Slight 

990 

86 

Practically recovered. 

18 

F. 

36 

Suic. melan. 

3 1 5 

7 

Moderate 

996 

110 

Slight improvement. 

»» 

F. 

36 

Si. melan. 

36° 

8 

„ 

99-6 

96 

Slight improvement. 

19 

F. 

35 

210 

6 I 

100*0 

104 

Recovery. 

20 

F. 

28 

Ac. mania 

360 

6; Slight 

99*2 

92 

Recovery. 

I21 

F. 

46 

Stup. melan. 270 

6 Decided 

100*4 

100 

Decided improvement. 

22 

F. 

3 » 

11 

525 

35 

None 

Normal 

Recovery. 

23 

F. 

28 

Del. melan. 

960 

64 

Slight 

Normal 

Decided improvement. 

24 

M. 

20 Stup. melan. 

420 

7 

99-8 

106 

No change. 

25 

F. 

35 

Del. melan. 

335 

7 

Moderate 

99-8 

120 

Decided improvement. 

26 

F. 

28 

Exc. melan. 360 

6 

Slight 

99*4 

IIO 

Almost recovered. 

27 

M. 

52 

Suic. melan. 360 

6 

99*2 

96 

No change. 

28 

F. 

34 Si. melan. 

240 

4 

Moderate 

99-6 

90 

Recovery. 

29 

F. 

39 

Suic. melan. 360 

6 

Decided 

99-6 

no Decided improvement. 

30 

F. 

30 

Exc. melan. 360 

6 

Slight 

99 *o 

106 

Slight improvement. 

31 

F. 

37 Si. melan. 

360 

6 

Moderate 

99-6 

116 

Decided improvement. 

32 

F. 

35 

Res. melan. 

570 

11 

Decided 

998 

108 

Decided improvement 

33 

F. 

45 

Si. melan. 

555 

9 

Slight 

99 *o 

106 

(temporary). 

No change. 

34 

1 

F. 

61 

11 

360 

6 

Decided 

100*2 

1,2 

Decided improvement. 


The results contained in this table may be summarised by 
themselves as follows : 


Males 

Females 

Total 


8 

31 

39 


Recov. 

I 

5 


Decid. impr. 
O 

16 

16 


Slightly impr. 
2 
9 

. 11 


No change. 

5 

1 


An investigation of the results produced by the action of 
thyroid in these thirty-nine cases renders it possible to draw 









































46 


TREATMENT OF INSANITY BY THYROID, [Jan., 


certain conclusions. It will be convenient to take up first of all 
the physical effects. It is very clearly proved that the thyroid 
gland contains a substance which is capable of exerting a very 
distinct physical influence. In view of many different experi¬ 
ments it is almost certainly proved that this substance is 
identical with the colloid material visible in microscopic sections 
of the gland. It has been named iodothyrin. Every case in 
which thyroid was given in the above series showed some reac¬ 
tion, though the degree varied much in different individuals. 
In most the reaction is evidenced by a rise of temperature, which 
in some may amount to as much as 4 0 F., but which is usually 
less, between 2° and 3 0 . In one or two exceptional cases it 
may be very slight. Dr. Bruce has already shown the influence 
of surrounding conditions of temperature in the reaction. This 
seems to point not only to an increased heat production but to 
a disturbance of heat regulation, as both combine to affect 
the temperature. 

Besides this effect, thyroid also produces a marked influence 
on the pulse, both in its rate and its character. In all the above 
eases this change was constant, though its amount varied. In 
most of them the rate was considerably increased, but the more 
constant change was one affecting its strength and volume, both 
of which were diminished. As this change in the pulse is 
apparently more constant, and is a source of greater danger 
than any rise of temperature is likely to be, it follows that the 
pulse is a much better guide than the temperature in estimating 
the effect of thyroid, and in judging when it has been pushed 
far enough. There is another difference in the way in which 
thyroid affects the temperature and pulse respectively. This 
consists in the fact that the temperature ceases to be affected 
after a few days, usually six or seven, while the pulse continues 
to be affected so long as the drug is given. In the case of the 
latter also the effect is cumulative, so that for this additional 
reason the pulse ought always to be carefully investigated so 
long as thyroid is being administered. 

A study of the reaction in the various cases shows what had 
indeed been already ascertained as regards the dosage and period 
of administration which is likely to produce the best results. 
The usual amount given was sixty grains, continued for six 
days. In some which recovered a less dosage than this sufficed 
to effect a cure, and it is always open to conjecture whether a 


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1899.] BY JAS. MIDDLEMASS, M.D., F.R.C.P.E. 47 

case which recovers would not have done so with a less dosage 
than that stated. It is, however, certain that that amount can 
be safely given, and is most likely to effect the physical and 
mental changes desired. In three cases the plan was tried of 
giving small doses of fifteen grains daily for a prolonged period. 
It is hardly sound to draw conclusions from such slender facts, 
but it may be stated that one recovered (Case 22), and that the 
other two both showed decided improvement. In view of these 
facts it would be worth while making a further trial of this 
method, as it is unattended by any risk. It would also assist 
in settling the question as to whether the production of a 
marked physical reaction is really essential in the bringing 
about of a cure. 

More than one case exhibits the necessity for care in 
examining the physical condition of the patient before the drug 
is given. As already stated this was recognised, and due care 
exercised, especially in the examination of the lungs. But it is 
often difficult to detect latent phthisical processes, and it will 
hardly be possible to exclude from thyroid treatment every case 
which has such a latent weakness. In the above series no case 
of cardiac complication occurred, while three developed lung 
symptoms. It is therefore necessary to examine the chest 
regularly, and to watch the temperature curve carefully. 

In many cases thyroid also causes digestive disturbance. It 
is important to avoid this if possible, as there is considerable 
loss of weight from the drug alone, and disturbance of digestion 
interferes with the regaining of this when treatment has ceased. 
The recovery of weight lost seems to be an important element 
in bringing about a cure subsequently, though it is not abso¬ 
lutely essential. The best means to avoid gastric disturbance 
appears to be the giving of the drug in warm soup, beef tea, or 
bovril, and the placing of the patient on a light, easily digested 
diet. It appears undesirable to give thyroid to patients who 
are steadily losing weight, or who are badly nourished. In 
them it would be more desirable to try the effect of prolonged 
small doses. 

I come now to consider the mental effects produced by the 
thyroid. It may at once be said that in almost every case 
some mental change was observed, though the degree of the 
change varied much in different cases. In many it exhibited 
a distinctly stimulating action, and this was particularly notice- 




































48 


TREATMENT OF INSANITY BY THYROID, [Jan., 


able in one or two. In most cases also there was a tendency 
towards the reproduction of the original mental symptoms. If, 
for instance, suicidal feelings had been present at the outset of 
the attack, they were frequently manifested once more during a 
course of thyroid. Such a fact obviously indicates the necessity 
for attention to mental symptoms during the treatment. It 
was also remarkable that in several cases the emotional con¬ 
dition underwent a complete transformation. Whether or not 
this was due to the stimulating action on the cortex already 
described it is impossible to say, as we are not yet able to 
define on what physical conditions the different emotional 
states depend. 

As already stated, recovery followed in six cases out of 
thirty-four, but a careful study of these does not yet permit of 
any satisfactory explanation of how the thyroid really acts in 
bringing about this result. We do not yet know sufficient 
about the pathological conditions which constitute insanity, nor 
of the action of thyroid in modifying these, to be able to draw 
reliable conclusions. One thing, however, is almost certain, and 
that is that the beneficial effect of thyroid is altogether 
independent of the physical reaction produced, at least in so 
far as the temperature and pulse are concerned. These are 
certainly not the only physical effects which thyroid is capable of 
exerting, as we know that these may be very slightly affected, 
and yet the body weight may decrease rapidly. A more 
prolonged and searching investigation is obviously necessary 
before a full explanation is possible. 

In spite of a fairly extensive use of thyroid it seems still im¬ 
possible to foretell what the mental result of its use will be, or in 
what forms of mental disease it is most beneficial. Most of 
those treated suffered from melancholia in some form or other, 
and all of those who recovered, except one, laboured under this 
form of mental disease. As regards age, all of those who 
recovered were between twenty-four and thirty-five, which is the 
period in which recovery under other forms of treatment is 
most likely to occur. But if the ages of those who showed 
decided improvement be taken into account, this conclusion 
must be somewhat modified ; and the experience of others 
tends in the same direction. It is also of interest to note that 
the female sex appears to be much more susceptible to benefit 
from thyroid treatment than the male. The table already 


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1899.] BY JAS. MIDDLEMASS, M.D., F.R.C.P.E. 49 

given brings this out clearly. The explanation, however, is 
still to seek. 

Another interesting conclusion which may be drawn is that 
in very many cases a course of thyroid modifies the rapidity 
with which dementia progresses, even when a cure is not 
effected. Experience has abundantly shown that with proper 
precautions no case is made worse by the treatment. It seems, 
therefore, strongly advisable that no case should be allowed to 
become demented without a trial of thyroid being made. This 
brings us to another important point, which was drawn atten¬ 
tion to by Dr. Bruce in his original paper, viz. the possibility of 
a course of thyroid being used as a diagnostic of the curability of 
any case of mental disease. At first it was not possible to be 
certain of this, but after four years’ experience it appears that 
only one case out of two hundred known individually by me has 
recovered who did not do so after thyroid. Even this case is 
a doubtful one, as she had had thyroid only a few months 
before. If the above conclusion should prove to be true, a 
considerable step in advance in the way of prognosis will have 
been made. 

The conclusions come to above may be summed up in the 
following propositions : 

1. The thyroid gland contains one or more substances which, 
on administration, are capable of exerting a powerful influence 
on the system. 

2. In most cases this is evidenced by a rise of temperature, 
which may reach as much as four degrees above the normal. 

3. In a certain number of cases this rise of temperature is 
very slight or absent altogether. 

4. It is at present impossible to predict in which cases the 
rise will occur, and in which it will be absent. 

5. The surrounding conditions as to temperature to some 
extent influence the reaction. 

6. The rate and character of the pulse are affected in every 
case of thyroid administration. 

7. These changes consist in an increase of rate, and an initial 
increase followed by a decrease of volume of the pulse. 

8. As this is of constant occurrence while rise of temperature 
is not, the effect on the pulse should be the main guide as to 
when sufficient thyroid has been given. 

XLV. 


4 







































SO TREATMENT OF INSANITY BY THYROID, [J an -» 

9. As the drug is cumulative, and is not rapidly excreted, 
care must be exercised not to push it too far. 

10. As a rule the full beneficial effects are obtained by 
giving doses of 60 grains a day for six days, though in some 
less is sufficient, and in others 90 grains can be tolerated with¬ 
out ill effects. 

11. In a few cases small doses given for a prolonged period 
seem to produce a sufficient reaction. 

12. It is absolutely necessary in all cases before beginning 
treatment to make a careful physical examination of the lungs 
and heart. 

13. In cases where phthisis is active, or even dormant, the 
giving of thyroid always increases the activity of the diseased 
process. 

14. As thyroid also powerfully affects the heart, disease of 
that organ, especially such as causes irregularity of action, dis¬ 
tinctly contra-indicates its use. 

1 5. For the same reason, during administration of the larger 
doses the patient ought to be in bed, and remain there for a few 
days after it has been stopped. 

16. Thyroid causes digestive disturbance, which can usually 
be avoided by giving it in warm (not hot) beef tea, and by 
placing the patient on light easily digested diet. 

17. After the treatment has been stopped, tonics and extra 
diet may be given with beneficial results. 

18. In a large majority of cases thyroid also has a distinct 
effect on the mental condition. 

19. In many it has a distinctly stimulating action on the 
cerebral cortex. 

20. In most cases there is a* tendency towards the repro¬ 
duction of the original mental symptoms. 

21. The explanation of the action of thyroid in effecting 
recovery is still obscure. 

22. It is quite clear that the beneficial effect is altogether in¬ 
dependent of the temperature reaction. 

23. Therefore the initial idea of the treatment, viz. the induc¬ 
tion of a feverish condition, is not wholly justified by the results. 

24. It is at present wholly impossible to say what the 
mental result of thyroid treatment will be. 

25. It is equally impossible to say in what form of mental 
disease it will have a beneficial effect. 


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I 899.] BY JAS. MIDDLEMASS, M.D., F.R.C.P.E. 5 I 

26. In the series of cases given, the ages of those who 
recovered were all between twenty-four and thirty-five, and all 
but one suffered from some form of melancholia. 

27. The ages of those who showed decided improvement 
varied within much wider limits, and age does not seem to be 
the sole influence of the chances of recovery after thyroid any 
more than after any other form of treatment. 

28. The female sex seems to be more susceptible to im¬ 
provement after thyroid than the male. 

29. The reason for this is still unknown. 

30. Even in cases which are regarded as hopeless, thyroid 
often produces so great an improvement, that the degree of 
dementia is greatly lessened. 

31. In no case was the treatment followed by prejudicial 
results, provided care was taken to eliminate those suffering 
from physical disease. 

32. It is highly probable that thyroid furnishes a reliable 
diagnostic of the chances of recovery,—that is to say, if a patient 
does not improve under thyroid, the prospect of recovery is 
practically nil. 

I have made no attempt in this paper to discuss the previous 
literature of the subject, as it would have extended it beyond 
reasonable limits. For the same reason I have not always in¬ 
dicated the source of all the suggestions or conclusions made. 
My object has been simply to give an account of the experience 
gained in the treatment of a series of cases of insanity by 
means of thyroid, and the inferences which seem warrantable 
therefrom. It must be said that many of these we owe already 
to Dr. L. C. Bruce, who has the credit of first suggesting this 
plan of treatment. 


Discussion 

At the meeting of the Northern Division, Derby, October 12th, 1898. 

Dr. Legge said that Mickleover was the second asylum where the thyroid treat¬ 
ment was carried out to any considerable extent. They had used it at Mickleover 
in about seventy cases, and the conclusions arrived at had been practically the 
same as those narrated by Dr. Middlemass. On the male side they had got very 
few cases of improvement, and no case of actual recovery; whereas among the 
women there had been nine true recoveries. Several other cases had recovered, 
but had relapsed in a short time, whilst others had distinctly improved. To his 
mind Dr. Middlemass had rather minimised the dangers of the treatment, although 
he had admitted that a considerable amount of care was required. He (the speaker) 
had one case at death’s door, where physical examination failed to reveal the fact 
that the patient had heart disease. Very active measures had to be adopted to pre¬ 
vent a fatal result. In some cases which did not quite recover he had noticed a 



































52 


TREATMENT OF INSANITY BY THYROID, [Jan., 


most distinct improvement in the patient’s habits—they had become much cleaner. 
The treatment at first raised excessive hopes, and went through the phase that all 
new treatments had to undergo; but after this interval of time it might now be 
fairly said that this treatment placed a power in their hands which they had not 
possessed hitherto. It was scarcely likely that they would get as great a proportion 
of cures as Dr. Middlemass if they took cases at random, but in selected cases they 
might; and supposing only three per cent, of their patients recovered, that was 
very satisfactory. Could we employ any other drugs in the treatment of insanity 
and expect as good a result as a consequence of their use ? There had been con¬ 
siderable controversy as to whether the cure was due to the drug or to the reaction, 
and his (the speaker’s; opinion was that it was due to the reaction. He had a case 
now which he had treated four times with the drug—an epileptic dement of old 
standing, with wet and degraded habits, who, having been four times under thyroid, 
became each time perfectly well; but the improvement only lasted a few days. 
A similar change occurred in her after an attack of erysipelas. He was convinced 
that this was due to the reaction. In his experience those patients who had im¬ 
proved their mental state while suffering from physical illness had been mostly 
women. He had several cases where the temperature had apparently not risen 
above normal, but on taking the temperature in the vagina it had been found one 
and a half to two degrees above normal. The temperature of the axilla did not 
actually represent the body temperature in many cases. All the Mickleover cases 
had been treated by Burroughs and Wellcome’s tabloids, given in full doses, and 
continued foe nine days. It would be interesting to know what effect thyroid 
treatment had on insanity accompanied by goitre. Statistics on that point might 
be of some value in selecting cases for future treatment. The great majority of 
the successful cases at Mickleover had been not merely melancholia, but melan¬ 
cholia with stupor. The cutaneous system was noticeably affected; one patient 
covered with hair permanently recovered, and the hair disappeared. His experience 
led him to the conclusion that small doses long continued had little or no effect in 
producing recovery. 

Dr. Macphail said that he had taken great interest in the literature of the subject 
ever since they made their original researches at Derby four years ago, and he was 
surprised that certain medical men averred that they had found no effects whatever. 
He had found sometimes most alarming effects following the'doses recommended 
by Dr. Middlemass. In Derby asylum forty-two patients had undergone thyroid 
treatment in addition to the thirty cases described in the original paper by Dr. Bruce 
and himself. Of course they did not now give thyroid in the haphazard way they ori¬ 
ginally did, because they now reserved it for cases in which some benefit might be 
expected. Probably not one of those forty-two patients had thyroid during their first 
six months in the asylum. He did not claim that the recovery was always due to 
thyroid, but seventeen out of forty-two had improved sufficiently to be able to leave 
the institution. It was only right to say that thyroid had some influence in causing 
the improvement. Dr. Middlemass enumerated a long series of propositions, a large 
number of which were mentioned and emphasised in Dr. Bruce’s original paper. 
There were singularly few differences between the experiences of four years and 
the experiences of a few months. That would no doubt astonish those who had 
expected more perfect indications as to the use of thyroid. As to the bad effects 
of thyroid, he (the speaker) might say at once that he had seen a great many 
instances of the heart being prejudicially affected. At least four times he had had 
to stop thyroid on that account. In only one of those did he know that the patient 
had organic heart disease, while in three they had to stop the treatment because 
the heart was showing symptoms of failure. They tried thyroid in many cases 
suffering from goitre, and could not satisfy themselves that the least difference 
resulted. With regard to the growth of hair, he (the speaker) had had two patients 
under his care almost completely bald. They were subjected to the thyroid treat¬ 
ment, and in one it had no effect upon the baldness, but in the other the patient 
had since obtained a thick head of hair. He did not quite agree that melancholic 
cases alone benefited, as he had had cases of acute mania which had improved 
under the thyroid treatment. He had not yet been able to come to a definite con¬ 
clusion as to why the improvement resulted—whether it was the specific action of 
the drug or the reaction ; but as far as his own knowledge went, he felt assured 
that the febrile reaction was alone the cause. He had approached the subject in a 


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RESPONSIBILITY OF THE INSANE. 


1899.] 


S 3 


reasonable manner and without expecting too much from the treatment, and there¬ 
fore had not been disappointed with the results attained. 

Dr. Greenwood said that from the little experience he had had of the treat¬ 
ment, he had formed the impression that the febrile reaction had everything to do 
with the improvement. The course of the case while under treatment was like 
that of a specific infectious disease. The patient had in many cases a rash, some¬ 
times the mere effect of sweating, but it often closely resembled the rash of scarlet 
fever. The effect also resembled the influence of acute bodily diseases in the 
course of mental diseases, producing in some cases a marked improvement, but 
in other cases accentuating the disorder. 

Dr. Middlemass said that there was no doubt there were dangers in the use 
of thyroid, but in his experience he had met none which could not be readily 
overcome. To his mind the danger of lung complications was the one to be most 
feared, and the one which required most attention. It was true that the heart 
was sometimes a source of trouble, but he always took particular care to examine 
that organ before placing the patient under treatment. He had had no such case, 
but Dr. Bruce had to modify the treatment in two cases, and on other occasions 
had to stop it altogether, although there had been no actual danger to the patient’s 
life. The pulse would show if the drug were being carried too far. With regard 
to the question of reaction, he must say that his own impression was that recovery 
was not entirely dependent upon the febrile reaction. He had tried the thyroid 
treatment on a patient affected with goitre, and there was neither mental recovery 
nor alteration in the size of the goitre. There was no doubt that where this mode 
of treatment was carried out systematically it influenced recovery to a remarkable 
extent. For instance, last year the recovery rate was 80 per cent., and they 
attributed that very largely to the use of thyroid. The majority of the cases were 
amongst women, and it was amongst them also that they had the largest number 
of recoveries. On the male side, on the contrary, the recovery rate remained the 
same. He had omitted in his paper to distinguish between cases suitable and 
unsuitable for treatment. He thought after trial that cases of general paralysis and 
epilepsy were, on the whole, unsuitable for treatment. The general impression 
was that the most likely cases to be benefited were those of stuporose melancholia, 
but not those cases alone. Thyroid was probably an absolutely certain diagnostic 
of the possibility of recovery, and must be considered of importance in this 
relation. 


The Responsibility of the Insane ; Should they be punished? 
A Reply to Dr. Mercier . By Reginald H. Noott, 
M.B., C.M., Broadmoor Criminal Asylum. 

I FEEL that some apology is due for again opening a subject 
which seemed to have been disposed of by the report of a 
special committee of this Association, which sat at the latter part 
of the year 1894. 

Considering that the report referred to was, with one very 
important amendment, adopted by the Association at the 
Annual Meeting held in London in 1896, I would not have 
presumed to refer to the subject again, had it not been that 










































54 RESPONSIBILITY OF THE INSANE, [Jan., 

Dr. Mercier put before us, at the Annual Meeting of the British 
Medical Association in Edinburgh a few weeks ago, an opinion 
so totally at variance with the views that have been held and 
fought for by the medical profession, that I think members of 
this Association should have an opportunity of expressing their 
views upon it. I hoped that this might have been done when 
Dr. Mercier read his paper, but unfortunately the time at the 
chairman’s disposal on that occasion was so short, that the dis¬ 
cussion came to an abrupt and, I venture to think, an unsatis¬ 
factory termination. Though the object of my remarks to-day 
is to reopen that discussion, it will be necessary shortly to 
review what has been said and done, during the last few years, 
on the subject of criminal responsibility. Both Dr. Weatherly 
in 1894 at Bristol, and Dr. Maudesley in 1895 in London, 
referred to the thankless and embarrassing task which anyone 
undertook who ventured to deal with a subject which has been 
worn threadbare without satisfactory result. I must apologise, 
therefore, if I repeat much that has been said before, and which 
no doubt will be said again. 

Although it has generally been held by the medical profes¬ 
sion that the law, as stated by the judges after the McNaghten 
trial in 1843, does not accord with medical science, it, was not 
until the year 1894, at the Annual Meeting of the British 
Medical Association at Bristol, that the question was fully dis¬ 
cussed by the medical profession, and on that occasion we had 
the advantage of hearing the opinion of Mr. Pitt-Lewis and 
other members of the legal profession on the subject. Up to 
that time, as I understand it, the difference of opinion between 
the two professions amounted to this : the legal opinion was 
that only certain forms and degrees of insanity should constitute 
irresponsibility; the medical profession generally not recog¬ 
nising the term “ partial insanity,” as understood by lawyers, 
maintained, and I think maintained rightly, that all forms and 
degrees of insanity should constitute irresponsibility. 

In conjunction with Dr. Weatherly, Dr. Mercier on that 
occasion opened the discussion, and Dr. Mercier gave us four 
definite reasons which in his opinion called for some alteration 
in the existing law. These four reasons were, first, that it 
does not cover all cases; secondly, that it leads to great 
variety and even contrariety of interpretation and of practice ; 
thirdly, that it leads to the stultification of judicial trials by the 


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subsequent certification of the convict; and fourthly, that it sets 
up a test of insanity which is inherently incapable of being 
satisfied. On that occasion he had the unanimous opinion of 
the meeting with him. At the recent meeting of the British 
Medical Association held in Edinburgh, Dr. Mercier read 
another paper on the same subject, which commenced thus :— 
“ The controversy between the medical and legal professions 
that has raged for so long round this subject is now rapidly 
subsiding. Judges, while adhering, as they consider themselves 
bound to do, to the terms of a well-known formula, contrive so 
to interpret that formula that upon the whole substantial justice 
is done. Medical men, recognising that upon the whole sub¬ 
stantial justice is done, cease to contend for an academically 
perfect formulation of the law, and recognise that such a formula 
might be found, after all, to be inapplicable to outlying and 
exceptional cases without that laxity of interpretation which 
renders the present law practically effectual.” 

This is practically a summary of the conclusion to which the 
special committee came, whose report I have already referred 
to. Dr. Mercier then dealt with the subject of criminal respon¬ 
sibility from quite a different point of view, and gave as his 
opinion, at the same time asking us to assent to it, that “ it is 
in many cases right and just to punish an insane person for 
wrong-doing.” Gentlemen, I feel very strongly that we should 
hesitate before endorsing an opinion which is so diametrically 
opposite to what has in later times been held to be the general 
medical opinion on the subject. If we adopt this theory of 
partial responsibility of the insane, the chief point of dispute 
over which we have fought so long with the legal profession 
ceases to exist, and we leave them masters of the field. 

As a rule the opinions of different members of the legal 
profession on the subject have been given from a purely legal 
point of view, without any attempt to study or inquire into the 
medical aspect of it. One eminent judge, however—the late 
Sir James Fitzjames Stephen—studied the subject in its 
medical aspects, in order to approach the subject, as far as was 
possible, with an unbiassed and open mind. He read a large 
amount of medical literature on the subject, and in his book on 
the History of the Criminal Law of England he devotes one 
chapter entirely to the “ Relation of Madness to Crime,” in 
which he states the conclusions to which he came. In reading 

































56 RESPONSIBILITY OF THE INSANE, [Jan., 

this chapter one cannot help being struck with the contra¬ 
dictory nature of some of these conclusions. Some of them 
seem to coincide exactly with what one has always supposed 
to be the general medical opinion ; others, on the contrary, very 
decidedly support the opinion which Dr. Mercier asks us now 
to adopt, viz. that some lunatics are responsible for their acts, 
and ought to be punished if they commit crimes. To illus¬ 
trate this point I shall quote some passages from the chapter 
referred to. In regard to the questions put to the judges 
after the trial of McNaghten, he says, “ It appears to me that, 
when carefully considered, they leave untouched the most 
difficult questions connected with the subject, and lay down 
propositions liable to be misunderstood ; ” and in another 
passage he says, “ The questions are so general in their terms, 
and the answers follow the words of the question so closely, 
that they leave untouched every state of facts which, though 
included under the general words of the questions, can never¬ 
theless be distinguished from them by circumstances which 
the House of Lords did not take into account in framing 
the questions ; ” while as opposed to this opinion, after ex¬ 
tremely subtle special pleading as to a possible meaning of the 
words “ know ” and “ wrong,” he says, “ I am of opinion that 
even if the answers given by the judges in McNaghten’s case 
are regarded as a binding declaration of the law of England, 
that law, as it stands, is that a man who by reason of mental 
disease is prevented from controlling his own conduct is not 
responsible for what he does. Again, while criticising these 
answers he says, “If they were so meant they certainly imply 
that the effect of insanity (if any) upon the emotions and the 
will is not to be taken into account in deciding whether an 
act done by an insane person did or did not amount to an 
offence ; . . . . and the proposition that the effect of disease 
upon the emotions and the will can never under any circum¬ 
stances affect the criminality of the acts of persons so afflicted 
is so surprising, and would, if strictly enforced, have such 
monstrous consequences, that something more than the implied 
assertion of it seems necessary before it is admitted to be part 
of the law of England ; ” and yet later on, when dealing with 
the question of insane impulses, which surely are the result of 
disease affecting the will, he says, “ I cannot see why such 
impulses, if they constitute the whole effect of the disease, 


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should excuse crime any more than other sudden and violent 
tempers.” 

In the following passages also Sir James Stephen uses argu¬ 
ments which decidedly support the medical view of the relation 
of insanity to self-control. He says, “ The facts that a man 
stammers, and that the pupils of his eyes are of different sizes, 
are in themselves no excuse for crime, but they may be the 
symptoms of general paralysis of the insane, which is one of the 
most fatal forms of the disease. Why should not the existence 
of a delusion be as significant as the existence of a stammer ? ” 
“ To a sane man the belief (however caused) that his finger was 
made of glass would supply no reason for taking any peculiar 
view about murder ; but if a man is mad, and such a belief is a 
symptom of his madness, there may be a connection between 
the delusion and the crime as insane as the delusion itself.” “ I 
do not think that it is expedient that a person unable to 
control his conduct should be the subject of legal punishment.” 

In spite of these opinions and conclusions, in the latter part 
of the same chapter he says, “ Parts of the conduct of mad 
people are not affected by their madness, and if such parts of 
their conduct are criminal they ought to be punished for it.” 
In another passage, “ I should be sorry to countenance the 
notion that the mere fact that an insane impulse is not resisted 
is to be taken as proof that it is irresistible;” and “ the practical 
inference from this seems to me to be that the law ought to 
recognise these various effects of madness. It ought, where 
madness is proved, to allow the jury to return any one of 
three verdicts—guilty ; guilty, but his power of self-control was 
diminished by insanity ; not guilty on the ground of insanity.” 
Following on which opinion he concludes by saying, “ The man 
who, though mad, was found guilty I would hang, but if the 
jury qualified their verdict in the manner suggested in respect 
of any offender, I think he should be sentenced,—if the case 
were murder, to penal servitude for life, or not less than, say, 
fourteen years; and in cases not capital to any punishment 
which might be inflicted upon a sane man.” Those, gentlemen, 
were the opinions of Sir James Stephen as to in what cases 
and to what extent the insane should be punished. To those 
opinions, practically, we commit ourselves if we endorse Dr. 
Mercier’s latest theory, viz. that “ it is in many cases right and 
just to punish an insane person for wrong-doing.” 























58 RESPONSIBILITY OF THE INSANE, [Jan., 

The position of the medical witness in cases in which a plea 
of insanity is entered is even under the present circumstances 
difficult, I might almost say farcical enough ; but if such partial 
responsibility of the insane as Dr. Mercier would have us 
recognise is accepted, the position of the medical witness 
would be so difficult that I cannot imagine anyone being 
capable of undertaking it. The task of “ making the punish¬ 
ment fit the crime ” would rest, of course, with the legal 
authorities, but they could hardly do so satisfactorily unless 
the degree of responsibility remaining to the unfortunate lunatic 
had been clearly demonstrated by competent medical witnesses. 
I do not know if medical evidence would then have more weight 
than it has at present. It certainly could not have less. Only 
a few months ago two men were tried at the Central Criminal 
Court before the same judge, in each of which cases the plea of 
insanity was entered. In the one case the medical evidence was 
very decidedly to the effect that the accused was sane. The 
jury found him insane, and he was ordered to be detained during 
Her Majesty’s pleasure. In the other case the medical evidence 
was to the effect that the accused was insane at the time the 
crime was committed. The judge summed up very strongly 
against the plea of insanity being borne out ; the jury found 
the prisoner guilty, and he was sentenced to death. He was 
afterwards medically examined by order of the Home Secretary, 
and as a result of the medical report he was ordered to be 
detained during Her Majesty’s pleasure. I imagine, if this theory 
of partial responsibility of the insane be accepted, that medical 
evidence in these cases would more than ever be discredited by 
the legal authorities ; at the same time there would be a greater 
temptation for medical witnesses to become medical advocates, 
which above everything is to be avoided. The object of medical 
witnesses in these cases should be to bring out all the facts 
bearing on the question, irrespective of whether such facts 
support the plea of insanity or otherwise. It is the business, 
of course, of legal counsel to bring about a conviction or an 
acquittal, as the case may be, on the facts as they appear to 
him. 

The following examples will explain my meaning, and will 
at the same time show to what an extraordinary degree the 
opinion as to the value of medical evidence will differ, even in 
the same individual, under different circumstances. An eminent 


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BY REGINALD H. NOOTT, M.B., C.M. 


59 


Q.C. engaged for the prosecution in a case of murder in which 
a plea of insanity had been entered, thus addressed the jury: 
“ Did the man know the nature of his act, and the consequences 
of it? If the jury found that he knew the act he committed 
was wrong, if he knew the quality of it, and if he knew what 
was right and wrong, and chose the wrong, then he was guilty 
of the crime with which he was charged. The learned counsel 
for the defence had asked them to decide that he was insane 
because the doctors said so, but that would be a very dangerous 
doctrine to admit. Their ordinary” knowledge told them that 
there was a strong leaning on the part of those who had the 
care and treatment of the insane towards thinking that people 
were insane who were peculiar, and if they were to act on the 
ipse dixit of a doctor, great danger would be incurred of the 
guilty escaping punishment/’ That very same gentleman, being 
engaged in a similar case for the defence , addressed the jury in 
these words : “You will observe whether, at the time he caused 
the death of the man, he was accountable for his actions. And 
further, I say that a person believed to be insane at the time 
he commits such a deed is properly allowed by the law to be 
excused from what would otherwise be a criminal action. What 
is there in the evidence upon it ? You have two of the most 
eminent physicians in your town examined on this subject. 
We all know that there is no science more difficult than that of 
finding out the state of a man’s mind, and it is only after y r ears 
of careful attention to the subject that an opinion can be formed 
on the matter. You have here two gentlemen who have had 
that experience in a striking degree, and they on oath tell y^ou, 
as scientific men, thoroughly conversant with lunacy' in all its 
forms, that in their deliberate judgment this man, who now sits 
before you, was at the time the deed was committed unable to 
distinguish between right and wrong. If y”OU return a verdict 
of guilty after you have such weighty opinion, y r ou throw upon 
yourselves the responsibility of placing your opinions of the 
state of the man’s mind—which I submit with all due respect 
you cannot be expected to do—against those gentlemen we 
have heard.” This is a truly remarkable difference of opinion 
as to the value of medical evidence in these cases. 

On what grounds does Dr. Mercier ask us to accept this 
theory of partial responsibility” of the insane ? Because, for the 
benefit of the community' at large, and for the patient himself, 






60 RESPONSIBILITY OF THE INSANE, [Jan., 

a patient who, while on parole, has got drunk, is refused his 
parole until such time as it is considered he has learnt such 
power of self-control as would be likely to prevent him from 
erring in that direction again. Because it is considered that a 
woman who has been “ fighting and smashing ” is not at that 
time a fit person to attend the weekly dance. Because, in order 
to maintain some sort of discipline and order in the asylum, 
and to protect other patients, one holds out various inducements 
to good behaviour, such as an allowance of tobacco, pocket- 
money, &c., and withdraws them when necessary on the principle 
of rewards and fines. 

I maintain most strongly that these should not be considered 
punishments at all. They are simply means by which we try 
to induce patients to exercise as much control as the nature 
of their disease will allow ; so that, by promoting as far as 
is possible a habit of self-control, we aim, in curable cases, at 
re-establishing such an amount of mental balance as will 
enable the patient to take his or her place in society ; or in 
chronic and incurable cases we aim at preserving a requisite 
amount of law and order, without which it would be quite im¬ 
possible to carry on any institution for the care of the insane. 
And in doing this a very large amount of discretion has to be 
used ; for it must be in every one’s experience who has had to 
do with the insane that a very large number are utterly 
unamenable to any such bestowal of privileges, and have to be 
managed in a different way ; e.g. by being placed in a part of 
the asylum where restriction of liberty is greater, and where 
there is a stronger staff of attendants, and in some cases 
treated by temporary seclusion. To my mind there is a great 
difference between this withdrawal of privilege and the punish¬ 
ment of sane crime by imprisonment, and, to use Dr. Mercier’s 
own words, the infliction of “ bread and skilly and the plank 
bed.” In the latter case it is recognised that the individual 
could and should have abstained from his wrong-doing. In the 
case of asylum patients who misbehave themselves, it is so far 
recognised that they cannot be considered responsible for their 
actions, that the character of what Dr. Mercier chooses to call 
punishments is quite different from the kind of punishments 
inflicted on sane criminals. For instance, no punishment takes 
the form of inflicting bodily pain, or the deprivation of the 
ordinary necessaries of food and rest, but only the withdrawal 


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6l 

of certain privileges, which may be called luxuries. Indeed, if 
we recognise this theory that the insane should under certain 
circumstances be punished, we shall be implanting in the minds 
of attendants and nurses a most dangerous notion of the 
management of the insane, and one which would undoubtedly 
lead to most serious consequences. At the same time we shall 
be recognising the legal opinion as to self-control in the insane, 
which is strongly exemplified in the following case quoted by 
Sir James Stephen:—“A woman felt suddenly and violently 
impelled to kill with a knife the child she was nursing. She 
threw away the knife, rushed out of the room, and asked a 
fellow-servant to sit with her, because she was 4 beset with evil 
thoughts.* She woke in the night with a similar impulse, but 
resisted it, saying, 4 O God, what horrible, what frightful 
thoughts !* She took some medicine and became calmer. On 
another occasion the same thing happened, but she still resisted. 
Ultimately the desire to harm the child died away.** Sir 
James Stephen makes the following remarks on the case:— 
“That the impulse was insane there can be little doubt, but 
sane or not it was obviously resistible, for it was in fact 
successfully resisted, and surely it was the legal duty of the 
woman to resist it.** So that we may suppose if she had not 
been able to resist it, and had killed the child, Sir James 
Stephen would have considered that she was responsible for 
the act, and should have been punished for it; yet he says 
44 that this impulse was insane there can be little doubt.*’ 

I hope, gentlemen, that I have made clear what dangers we 
are risking if we recognise this theory of partial responsibility 
of the insane. It seems to me that the bestowal and withdrawal 
of privileges is used in asylums exactly in the same way as a 
similar system is used in the nursery—for the purpose of 
training : in the latter case to promote self-control, which the 
child, on account of its want of experience and immature 
development, has never had ; in the former case to re-establish 
that self-control of which disease has deprived him. 

Discussion 

At the General Meeting, London, 13th October, 189S. 

The President. —The difficulty in approaching a discussion of this sort lies in 
the definition of terms,—what exactly Dr. Mercier has in his mind which he calls 
“ punishment,” and what Dr. Noott has in his mind which he denies to be “ punish- 








62 


RESPONSIBILITY OF THE INSANE, 


[Jan., 


ment.” I hope, therefore, that Dr. Mercier will be able to say what he means by 
49 punishment,” and what he means by “ partial responsibility.” We know that in 
Scotland recently the law did recognise partial responsibility. A man was con¬ 
demned to death for murder, and after his condemnation he was examined by a 
committee of experts. So far as one can gather, for the precise facts have not 
been published, their opinion was that although they could not certify him to be 
legally insane, yet his mental state was so far deteriorated that it would be 
improper to punish him to the full extent of the law. The consequence was a life 
sentence in the convict prison. I accept that as a valuable precedent. Another 
difficulty in a debate of this sort is that we are not dealing with concrete problems, 
but with theories. If we could have the exact facts relating to the individual man 
and the proposed punishment, then we could discuss the question with that accuracy 
which we cannot apply without great reservations to a series of academic pro¬ 
positions. 

Dr. McDowall. —The President has referred to a celebrated case, but when Dr. 
Mercier was reading his paper at Edinburgh he cited another where this gradation 
of punishment was awarded. A man appeared before one of the Scottish sheriffs a 
number of years ago, and before he was sentenced the sheriff deemed it prudent 
that he should consult one or two experts as to the man’s mental condition. They 
reported that they considered him mentally feeble, but partially responsible for his 
conduct, and therefore partially amenable to the law. The punishment was 
therefore modified on account of the prisoner’s mental condition. 

Dr. Weatherly. —It seems to me that we have here to deal with two questions: 
first, whether we are really satisfied with the existing state of the law, and the way 
in which the law is carried out. I do not think there can be any doubt that we are 
not satisfied. It was only the other day that I waited before a judge in regard to a 
case of melancholia, and was not allowed to open my mouth. There was a long 
legal argument, and then the prisoner was sentenced to death. Nevertheless he 
was ultimately reprieved. We must not overlook one great fact, that legislation 
and legal procedure in these cases are to a very great extent dominated by an 
hysterical, emotional, utterly absurd public opinion which is conceived in 
ignorance. (Hear, hear.) William Terriss happened to be killed by a lunatic; 
the public with one accord said, 44 Hang him ! ” If Terriss had been an unknown 
individual they would have said, 44 Let him go to Broadmoor.” Anybody who 
traces the history of legislation with regard to criminal responsibility must be 
impressed with the fact that from time to time it has been altered by this ignorant 
public opinion. I am perfectly certain that the law is unsatisfactory, and that it 
must be altered. In speaking of criminal responsibility I presume that we are 
talking of persons accused of murder. Now the lawyers invariably say that we go 
into the witness-box, for the defence or the prosecution, far too much as advocates 
instead of unbiassed witnesses. I admit it. We become too much of advocates, 
and why ? Because we know we are there to save from death an unfortunate 
creature who we implicitly believe is irresponsible for his act. That human nature 
which must come out—thank God !—in all of us, does to a certain extent make us 
advocates for the unfortunate prisoner, and possibly places us in a wrong light 
before judge and jury. There is this, therefore, in favour of Dr. Mercier’s conten¬ 
tion, that if partial responsibility were recognised by the law, we should not pose so 
much as advocates, and should have a great deal more liberty in stating our 
opinions. But when it comes to the word 44 punishment,” then I think there is 
something very wrong if that means that the prisoner, being a lunatic, is to endure 
the plank bed and work in a convict gang. 

The President. —What do you mean by a 44 lunatic ” ? 

Dr. Weatherly. — I mean a person who we, in the witness-box, state is suffering 
from such unsoundness of mind as to render him wholly irresponsible for the deed 
he has committed. 

Dr. Douglas. —I only rise to ask a question. Dr. Weatherly assumes that this 
is confined to murder and homicide; I certainly understood quite the contrary. 
(Hear, hear.) 

Dr. Stewart. —Suppose we confine our attention to cases of life and death, and 
suppose we merely think of the question as it affects some particular individual. 
Our minds must be affected as human beings by the thought that if we make a 
mistake—and medical men are liable to make mistakes—that unfortunate man maybe 


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63 

finally removed from showing, by his subsequent history and the subsequent develop¬ 
ments of his disease, that he was truly insane. Therefore I say let us not be bound by 
any ideas with regard to the position that the individual occupies, but rather limit 
our view to his mental state, irrespective of what he may suffer in the future. I 
look upon the opinion of Dr. Mercier as most dangerous. Are we or are we not to 
look upon a person who is insane—a lunatic, if you like, although I object to the 
term, as my father did before me, because it is an unscientific term—as a person 
responsible for his actions ? I think the whole thing is in that nutshell. Is that 
person to be condemned to any punishment whatsoever ? 

Dr. Douglas. —If I were asked to give an answer to the question as to the 
responsibility of the insane, I would say that in some cases they are responsible. I 
quite agree with Dr. Weatherly that the law does want alteration and reform; but 
consider how very indefinitely this question is put before us : “ The responsibility of 
the insane.” Who are they ? Are they those who go about amongst their fellow- 
men every day, and are capable of transacting business, or those who have to be 
confined in an asylum? Take the case referred to by Sir James Stephen—the 
woman who resisted the impulse to kill her child. The difficulty lies in the proof. 
There are cases in which some punishment should be meted out to the insane, and 
there are other cases in which punishment is out of the question. It is quite im¬ 
possible to formulate a general law to govern all cases of insanity. 

Dr. Newington. —It seems to me there are two distinct subjects before the 
meeting: (1) as to the responsibility or irresponsibility of the insane ; (2) are the 
insane to be punished? With regard to the first I have little to say; the discussion 
might go on for quite an indefinite time. My view coincides with what Dr. Weatherly 
has suggested. There will be no harmony between medical and legal demands 
until a third or middle course of treatment is established. We want a something 
so arranged that too much justice will not be done on one side and too little justice 
on the other. With regard to the second question, the position of this Association 
as to punishing the insane is in my opinion very much like the present position of 
another very important body, that is Her Majesty’s Government with regard to 
Fashoda. These matters can be discussed as subjects of high and dry philosophy, 
but as an Association we can but discuss them with a view to action. I do not think 
we can back up such an idea for a single moment. We have been extremely 
radical in improvements for many years past, but I do not think we can afford not 
to be conservative enough to at least stick where we are, and certainly not go back. 
There is a great deal in what Dr. Mercier says about the power of convincing 
insane individuals by rather unpleasant means that they might do better than 
pursue their insane course of conduct; but it is not for us to enter into any dis¬ 
cussion. Perhaps it may be rather too much of a Sunday-school way of treating it, 
but I do not think we should in any way discuss this matter with any idea of for¬ 
saking what we consider to be our true principles. 

Dr. MacDonald. —I rise to support what Dr. Newington has just said, and to 
take exception to the statement put forward by Dr. Mercier that the insane should 
be punished. I will only speak for myself as regards the asylum over which I 
have the honour to preside. I do not authorise punishment. If Dr. Mercier applies 
the term "punishment” to methods of treatment such as withholding tobacco, 
amusements, and the like, we must disagree as to the meaning of the word. If we 
apply a treatment which is very repugnant to a patient, and have to enforce it, is 
that punishment ? If you have to forcibly feed a case of melancholia, is that 
punishment ? If Dr. Mercier says that because a patient has had a luxury stopped 
it is a punishment, I deny it in toto. I regret that Dr. Mercier should convey 
such an impression to the public as is generally conveyed by the word " punish¬ 
ment,” and feel sure that methods of treatment generally approved will not be 
done away with because of his opinions. 

Dr. Jones. —I should like very much to endorse the remarks of Dr. Newington. 
Nearly all of us are responsible for the treatment of the insane, and I think it would 
be a very sad thing if it went into the world from this Association that punishment 
in any shape or form is approved by us. I quite agree that a good deal of this dis¬ 
cussion is due to a misunderstanding of terms. If intimidation, and if argument 
such as Dr. Mercier advances, are to be the basis of our treatment, I think the 
sooner we change the use of our terms the better. I have seen the effect of putting 
patients into padded rooms, seclusion, and the effect of withdrawal of patients from 






64 RESPONSIBILITY OF THE INSANE, [Jan., 

dances, and my experience is that it shocks and embitters, and certainly humiliates 
these patients. 

Dr. Rayner. —There is really a great need of definition. We want to define 
what is punishment, and what is treatment. For mv own part, I certainly think that 
every phase of insanity should be treated; and I believe until the law gets rid of the 
idea of punishment, and substitutes the idea of treatment for crimes, we shall always 
be in opposition to the law. 

Dr. Langdon-Down. —It appears to me that the treatment of children and treat¬ 
ment of insane persons should be placed in the same category. We should lay 
before the court all the circumstances and facts, and leave it to the jury to return 
their verdict, and to say how far the prisoner should be held answerable for his con¬ 
duct. Dr. Mercier avoided the necessity of stating whether the persons he referred 
to were technically insane or not. 

Dr. Mercier.— -Sir, I have listened with great attention to this very interesting 
discussion. I have waited, and waited in vain, for something to answer. I hoped 
that my adversaries might advance arguments. I regret to find I have been dis¬ 
appointed. A great deal has been said about things that had nothing whatever to 
do with my position in Edinburgh, and I remind you that the title of Dr. Noott’s 
paper is that it is a reply to that position, and therefore I am justified in expressing 
regret that a lot of things have been brought in which were not alluded to by me at 
all. Dr. Noott tells us that it is the business of counsel to do the best he can for 
the side for which he is engaged. If for the prosecution he must endeavour to 
obtain a conviction, and if for the defence he must endeavour to obtain an acquittal. 
Well, I do not consider that very nefarious conduct. Dr. Newington says that we 
ought not to discuss this subject. 

Dr. Newington. —With the result or intention of forsaking our principles. 

Dr. Mercier. —I have the greatest respect for him, but I hope that we shall develop 
our principles and elevate them to greater principles than they were before. I 
utterly repudiate the notion that there is anything connected with insanity that this 
Association ought not to discuss. As to Dr. Noott’s paper and the other criticisms, 
the answer I give to-day to all my critics is simply, This is exactly what I pro¬ 
phesied in my original paper at Edinburgh. I said then that I read it with the full 
consciousness that my views would be either misunderstood or wilfully misinter¬ 
preted, and that I should be called all sorts of names, and told that I advocated a 
plank bed and skilly for every lunatic. It is what usually happens to those who 
would benefit their fellows, and we must expect it, and not be disappointed when we 
get it. Our President has very truly stated that the matter is very largely a question 
of definition of terms. 1 say these measures you take are punishment; you say they 
are not. You admit that these measures are desirable ana necessary, and that you 
use them. You all admit that you do use towards patients in every asylum in the 
country certain measures—withdrawing certain privileges—and you say this is not 
punishment. You say it is abominable to call it punishment; to say that we are 

f inishing lunatics is deserting all our old principles and bringing us down to a low 
evel, and publishing to the world our own degradation. I maintain that when you 
stop a man’s tobacco or beer, or knock him off extra diet, prevent his going to the 
weekly dance, or stop his parole, or withdraw other privileges, it is every bit as 
much a punishment as if you withdrew from him the privilege of going about at 
large by locking him up. (No, no.) It is not so severe a punishment, but it is a 
punishment. We will take a case and I will ask for an answer. A man is brought 
up before the beaks and given the alternative of 5s. or seven days. Will anybody 
deny that the fine is not as much a punishment as the imprisonment ? (Yes.) 
What is a fine? Taking money out of a man’s pocket; stopping his wages; 
diminishing his income. That is what I do when I have a patient who is destructive 
and tears the paper off the wall, breaks up the furniture, steals my books, and tears 
the covers off. I say to him, “ You see this book; it will have to go and be rebound, 
and I shall charge you for the damage by stopping it from your pocket-money.’* 
That is a fine just as much as if I had taken him up to the court and he had been 
fined with an alternative. Both are punishments, and you cannot distinguish 
between them; and if it is punishment to withdraw money, equally is it punish¬ 
ment to withdraw the product of money. You withdraw a man’s tobacco, and say 
it is not a punishment. Try that discipline on yourself, and say whether it is 
punishment or no. I say it is punishment when pain is inflicted upon a person in 


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1899 -] 


BY REGINALD H. NOOTT, M.B., C.M. 


65 

any way, either by flogging or by the withdrawal of his tobacco, or what not, for the 
sake of the moral effect,—in short, for the sake of aiding his self-control; and that 
is Dr. Noott’s own position. He says we must treat lunatics very much in the 
same way as children are treated in the nursery. How do we treat children 
in the nursery? We aid self-control by a graduated system of rewards and 
withdrawals of rewards and other punishments. Mind you, I call it punishment, 
because I want to make your flesh creep. I want to bring it home to you 
what you have been doing all these years. I do not say to my patient, “ I am 
going to punish you because you have torn the back off my book.” I say, 
“ I will give you an aid to self-control.” The matter is one of words and names. 
You are all agreed as to the facts, and whenever you cause pain to any person by 
any means whatever, for the sake of the moral result of aiding self-control, you are 
punishing him. (No, no.) 

Dr. Noott misrepresents me, of course unintentionally, when he says that I would 
punish under certain circumstances an insane man as if he were sane. Evidently he 
has not read my paper. Among the three principles I laid down were these:—(i) 
That no insane person ought to be punished for any offence with the same severity 
as a sane person ought to be punished. (2) That there are many cases in which an 
insane person should not be punished at all for wrong-doing. How then can it be 
said that I would punish the insane as if they were sane? We should not punish 
a girl maniac who had murdered her child; we should not punish a general para¬ 
lytic who had stolen something; but let us remember this, that it is not only the 
moral, the virtuous, and the good people who go out of their minds. Suppose a 
professional thief becomes insane. Well, gentlemen, we know it is a matter of 
daily occurrence that after people have become insane they continue to carry on 
their professions, more or less imperfectly and for a certain length of time; and the 
professional thief does the same until his insanity is recognised. Is he not to be 
punished at all ? I admit that he is not to be punished with the same severity. 
Are not the business transactions of the merchant who becomes insane, and during 
the incipient period of his insanity carries on his business in a capable manner, 
perfectly valid ? And has he not to reap the consequences, for good or for evil ? 
So with the thief who continues to carry on his business. Is he not to be treated as 
to a very large extent sane, although he is to some extent insane ? Is he, too, not to 
reap the consequences of his acts ? The whole of this discussion pivots on one 
point, which I thought had been abandoned even by the laity, but which appears to 
remain clinging in the minds of some of my confreres, —that when a man is insane 
he is totally insane, a completely altered being. A man may be insane to a very 
trifling extent, and over a very large sphere of his conduct he may be responsible; 
and if in this sphere of his conduct he commits wrong he ought to be punished. Or 
he may be insane over a large area, and sane in but a small area of conduct, and 
the proportion between the sane and insane area of conduct varies in every case. 
The difficulty we have in courts of law and in our daily practice is in determining 
in a man's conduct how much belongs to the sane and how much to the insane. 
Until we recognise that, and root out from our minds the idea that because a man 
is insane therefore he is a totally altered being, and consequently absolutely and 
utterly irresponsible for everything he does, we shall never understand insanity. 

The President. —Naturally, when Dr. Mercier uses the word punishment it 
irritates. Now-a-days, in any case, we are very much disinclined to talk about 
punishment in the sense of retribution. What we ask for is treatment. Dr. Mercier 
may call withdrawal of the trivial awards of asylum methods “punishment,” but I re¬ 
gret that such a strong word has been introduced into our discussion. It is liable to 
gross and wide-spread misunderstanding. He says that no one would punish the 
insane mother who kills her child. But she is sent to Broadmoor, she is deprived of 
liberty. Is that not a severe punishment ? The real difficulty is not with regard 
to the absolute lunatic, but with regard to those who are partially insane. If we 
have only to deal with patients who are so insane that the man in the street can 
recognise their malady, we can easily induce the law to take our view; but when a 
difficult diagnosis has to be made, when we desire that the prisoner should have the 
benefit of the doubt arising from our imperfect knowledge, it seems to me that those 
cases on the borderland will always offer the greatest possible difficulty. 

Dr. Noott, in reply, said : I consider anyone to be insane who is fit to be certified 
as of unsound mind. I say that such a person ought not to be punished. Dr. 

XLV. * 5 




66 LUNACY IN PRIVATE PRACTICE, [Jan., 

Merrier chooses to call the withdrawal of tobacco and certain privileges “ punish* 
merits,” and if this definition existed only in his own mind as regards the insane, no 
harm would be done; but, unfortunately, his opinions were widely published, and 
the general public will very quickly get into their heads that we are going back to 
the time when the insane were very severely treated. Dr. Mercier also said that 
the medical witnesses should be able to give the judge so much assistance that 
mitigated punishments should be inflicted. That means, under some circumstances, 
the insane should be punished because in his opinion all insane people are not 
totally insane. I absolutely disagree with him. If a person is insane, I maintain 
it is impossible for any one to say how far he is insane, how far he is responsible 
or irresponsible. (Hear, hear.) As to the case mentioned by Sir James Stephen 
as having had a delusion that his finger was made of glass, no one could say how 
far that delusion might affect that person’s mind. I maintain that if the person is 
insane at all, he is totally insane, and that we cannot recognise any such thing as 
partial insanity. Dr. Merrier says, “ Is the thief to be punished if he becomes 
insane ? ” I do not see why the thief who has become insane should be differently 
treated from any ordinary person. 


Lunacy in Private Practice . By H. C. Bristowe, M.D., 

Wrington. 

I DESIRE to-day to show, to some extent, the difficulties the 
general practitioner of medicine has to contend with in the 
treatment of lunacy ; difficulties certainly unknown in public 
asylums, and only partially appreciated in private institutions. 

The first, and I may add the natural impulse of every 
medical man in private practice, on being called to a case of 
insanity, is to relieve himself of a certain amount of responsibility, 
and at the same time to do what he considers best for his 
patient, by sending him to an asylum with the least possible 
delay. No doubt that in itself is a very proper course to 
pursue, but there are many difficulties in the way. The case 
may be of such a character that certification is a difficult 
matter ; then the relations raise objections ; perhaps the magis¬ 
trates refuse to make the order, or finally the patient may be of 
the quiet demented type better fitted for treatment at home, or 
in the lunatic ward of a workhouse. This accommodation, 
however, is often wanting, and the patient becomes one of those 
unfortunate outcasts who is unfit to be kept at home, and is 
yet unfit for asylum care. 

I may say at once, as a foundation on which to build my 
whole subject, that in private practice the treatment of an insane 


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1899] 


BY H. C. BRISTOWE, M.D. 


67 


person is essentially the treatment of his friends. Many 
patients who become hopeless dements might never have been 
lost to the intellectual world had their friends been persuaded 
of the necessity of prompt and active treatment. I cannot 
over-estimate the dangers of delay, both immediate and remote. 

I was called to see a patient one Sunday morning—a man who 
had been sent a distance of many miles from his home for a 
change of air, because he was depressed and unable to manage 
his business. He was suffering from acute melancholia of a 
suicidal type. I gave the friends full directions, and warned 
them of the apparent dangers, and left with the relieving officer 
to make arrangements for his immediate removal. In an hour, 
before a magistrate could be seen, the patient had cut his throat. 
Was he sane when he left his home ? Why was the patient 
sent for a holiday instead of to an asylum ? The answer can 
only be a presumptive one. Another point arises from this 
case—why should not urgency orders exist for pauper as well 
as for private patients? 

Delay is more often caused by the unwillingness of friends to 
have the patient sent away. In some cases the prejudice is so 
strong that treatment must be carried on in a private house, 
which is generally most unfit for such a purpose. For instance, 
a case of puerperal insanity was kept at home because at first 
the husband would not believe his wife to be mad, and later on 
could not be persuaded to part with her, believing she could be 
just as easily cured at home. Eventually he did consent, but 
too late, for though she has now left the asylum she has never 
properly recovered. 

Why, in the many courses of lectures given under the 
auspices of the St. John’s Ambulance Association, cannot one 
lecture be added to teach the public the seriousness of mental 
alienation, and the dangers caused by the delay of active treat¬ 
ment ? Most uneducated persons would prefer that their rela¬ 
tions had a limb amputated in their own homes than allow 
them to spend a month or two in an asylum, even with the 
prospect of their eventually becoming useful members of society ; 
when too late they are glad enough to be rid of them. 

Another serious difficulty lies in obtaining orders from the 
justices. At the same time I must say that some of them 
take a great deal of trouble over the matter. Some, on the 
grounds that they are not experts, take a judicial view of the 







68 LUNACY IN PRIVATE PRACTICE, [Jan., 

case ; but others, not content with weighing the evidence put 
before them, attempt to test the mental condition of the 
patients. The result is often disastrous. These same justices, 
when seated on the bench, pass judgment on the evidence 
before them as a matter of course, and do not require that they 
shall themselves have witnessed the crime before convicting the 
prisoner. They seem to forget that a medical certificate of in¬ 
sanity is a statement on oath. 

A very different form of difficulty which we have to contend 
with is the inability that many persons, even members of our own 
profession, have in detecting insanity in its earlier stages. In¬ 
deed, not infrequently are well-marked cases of insanity regarded 
by the medical attendant as cases of hysteria. Perhaps some 
of the greatest mistakes in this respect are perpetrated by 
specialists in diseases of women. 

The following case gave me much trouble and anxiety. A 
young lady begins to show morbid mental symptoms, and her 
mother, as we should expect, discovers that her menses have 
ceased. The unfortunate patient is taken at once to the gynae¬ 
cologist, who straightway treats her for amenorrhoea. Her 
mind is at once fixed on her sexual organs, and from that date 
erotomania to a greater or less extent ensues, and in addition 
to the risk of permanent mental aberration she runs a risk of 
being dishonoured by the first reprobate thrown in her way. 

I must deal shortly with those patients who must be treated 
in their own homes. In the houses of the well-to-do, after the 
proper treatment by their friends, which is by no means an easy 
matter, there is* very little to be said which does not hold good 
for those cases removed to an asylum. One’s time is taken up 
in preventing or counteracting the injudicious actions of those 
around them. But in this class a trained attendant is so easily 
obtained that one can count on a good deal of assistance. In 
the lower middle classes, however, trained attendants are too 
expensive, and when space is limited the difficulties become far 
more serious. It is common to find that an injudicious act has 
caused a relapse in a patient who was progressing favourably. 
If there is a well-marked suicidal tendency we are often told that 
the patient does not really mean to carry out his threats. His 
friends consequently fail to have him properly watched, and the 
disastrous results are recorded in the daily press. Although in 
adverse surroundings it is difficult to bring moral influences to 


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BY H. C. BRISTOWE, M.D. 


1899.] 


69 


bear on a patient, a good deal can be done to guide him 
along the right path. 

In the lower classes the outlook is almost hopeless unless 
the patient can be removed to an asylum. But in this very 
hopelessness a gleam of hope arises, for the burden of an insane 
relation is so great that relief is soon sought, but only if the case 
be acute and troublesome. 

My experience confirms me in the belief that the proper 
treatment of insanity can only be conducted satisfactorily in 
asylums. Where wealth is at command of course much may 
be done by careful home treatment, or well-regulated travelling ; 
but how much better asylum treatment is can only be judged 
by those who have known both. Where wealth is wanting it 
is appalling that the prejudice wrongfully attached to the name 
“asylum” should cause so many hopeless cases. To the 
general public the lunatic asylum has a portal over which 
is written the dread motto, “ Abandon hope, all ye that enter 
here.” We may in the course of years teach people the real 
nature and the value of these institutions, but meanwhile it is 
this difficulty of a name which fetters the action of the general 
practitioner, and causes accumulation of the chronic insane. 

As regards those on the border between sanity and insanity, 
in my experience the majority are much better treated outside 
the walls of an asylum, so long as they are capable of 
such self-control as maintains them useful members of society ; 
but when they pass beyond this boundary they should be placed 
in asylum care if medical men are found bold enough to certify 
them. 

No doubt it was for the benefit of these borderland patients 
that the law as to voluntary boarders was made. Does this 
law help them ? In my limited and unfortunate experience it 
does not, for in such cases certification has nearly always proved 
ultimately necessary. 

Finally, what is to be done with aged harmless dements ? 
Many are kept quietly and peaceably at home, and do well there ; 
but where homes are cramped and money scarce, and the 
workhouse impossible, it becomes our duty to send them to an 
asylum, although many of us in general practice are just as 
unwilling to do this as the authorities are to receive them. 


Discussion at the meeting of the South-Western Division, Bath, October 19th, 
1898. See “ Notes and News,” infra. 









70 OBSERVATIONS ON CLASSIFICATION OF INSANITY, [Jan., 


Observations on the Classification of Insanity.Q) By 
Edwin Stephen Pasmore, M.D.Lond., M.R.C.P.Lond.; 

Second Assistant Medical Officer, London County Asylum, 

Banstead. 

In introducing to your notice this afternoon a few observa¬ 
tions on the classification of insanity, I feel able to touch only 
the edge of the fringe of a very large subject—a subject as 
abstruse as it is extremely interesting. In the course of some 
original work I have been carrying on at Banstead Asylum 
during the last few years, and which I hope to publish shortly, 
I was struck, whilst noting the mental states of cases, by the 
frequency with which some mental symptoms were always 
associated. This grouping, as it were, of symptoms differed in 
different states of mind. For instance, in one particular state 
of depression the symptoms arranged themselves in three groups 
in certain states of body I shall hereafter mention, in the 
following order: 

1. Depression with morbid ideas and temporary impairment 
of memory. 

2 . The same condition as above with hallucinations of 
hearing. 

3 . Depression with morbid ideas, delusions of persecution, 
and hallucinations of hearing, but without impairment of 
memory. 

Other psychic phenomena such as stupor, refusal of food, 
and suicidal tendency would in some cases be present. 

Clinical history .—The following is the usual clinical mental 
history of this association of symptoms. 

The first symptom noticeable is depression. This depres¬ 
sion, starting from slight lowness of spirits and passing through 
phases of intermediary character, later may be described as a 
state of saturated grief; the mind becoming apathetic and intro¬ 
spective, energy and will are gradually lost. 

Everything becomes irksome, the performance of the ordinary 
and necessary duties of life are neglected in consequence, and 
then sleeplessness follows. 

A little later on this state of depression is grafted, probably 
through sleeplessness, a state of general confusion of ideas. The 
sufferer goes about in a dreamy, absent-minded manner— 


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1899] 


BY E. S. PASMORE, M.D. 


stuporosed, in fact,—at times recognising, but not always being 
able to appreciate what is going on around. 

With the onset of this confusion of ideas the memory begins 
to fail, and the faculties of attention, retention, recollection, and 
recognition sink into abeyance. This fact appears to increase 
the emotional condition, and the state of mind at this period 
(which may be lachrymosed, restless, resistive, with at times 
refusal of food and suicidal tendencies) is markedly characterised 
by intense mental suffering, as is evidenced by the anguished, 
terrified, and dejected expression. 

This stage in the history of the disorder might continue for 
an indefinite period, but sometimes terminates in sudden re¬ 
covery if the patient be young ; or, on the other hand, passes 
on into a state of early dementia if the patient be much beyond 
the middle period of life. 

Should, however, the case show a psychic progression, im¬ 
provement takes place for a time . The stupor and general con¬ 
fusion pass off, the memory improves, the expression changes, 
and the patient will engage in conversation if addressed. Then, 
by this means, it will be found that a little before or coincidently 
with this apparent recovery, hallucinations, from mere sounds to 
well-recognised utterances, develop. 

On these hallucinations theories or delusions are generally 
based, at first fleeting and changeable in character as a rule, 
later to become of a fixed persecutional type and ascribed to 
unseen agency, especially if the hallucinations take the form of 
well-defined or familiar voices. 

These psychic developments, at times of such a nature as 
likely to give rise to fears or suspicions of personal danger, 
might lead to maniacal outbursts, and acts of a most violent, 
dangerous, suicidal, or homicidal character. 

As the case goes on the disorder becomes one of chronic 
delusional insanity, with fixed ideas of persecution, and ends 
finally as dementia. 

Before this end comes, in some cases, if the physical state is 
not a grave one, some intercurrent fatal malady might terminate 
life. On the other hand, recovery takes place if the physical 
state is one amenable to treatment , and the mental condition is 
discovered at an early stage in its development before marked 
hallucinations or pronounced delusions manifest themselves . With 
recurring attacks, as the symptoms appear to become more and 

































72 OBSERVATIONS ON CLASSIFICATION OF INSANITY, [Jan., 


more intensified with each successive onset, the chances of 
recovery become less and less. 

Such, then, as completely as I have been able to trace it, is 
the clinical mental history of the symptom-combine which I 
propose to designate “ deprimentia.” 

In 500 cases I have investigated the morbid physical states 
of body which were associated with this train of symptoms 
belonged to the following types :—Diabetes, gout, anaemia, heart 
disease due to failure of function, /. e . incompetence, disease of 
any of the glands of the body causing loss of function of those 
glands, due to primary disease, chronic jaundice through reten¬ 
tion of bile, &c., amenorrhoea, metrorrhagia, and menorrhagia 
at all ages, chronic disease of the lungs (excluding phthisis 
and specific diseases), gastritis or enteritis (chronic or acute) 
where the condition is due to primary affection of the glands 
of the intestinal tract, so perverting the normal secretion. 

These morbid states as far as our present knowledge goes 
must not be traceable to any external agent . This fact is most 
important. 

At first sight it would appear that this grouping of mental 
symptoms was common, but on closer examination it will be 
found that such is not the case. The morbid physical states thus 
met with may be classified as follows : 

(I) Excess of some normal constituent:—(1) Glycosuria; 
(2) Diabetes ; (3) Gout ; (4) Jaundice. Sugar, uric acid, and 
bile being normal constituents of the blood. 

(II) Deficiency of some normal constituent:—(1) Anaemia, 
due to deficiency of haemoglobin ; (2) Exophthalmic goitre, 
which Mr. Horsley has lately attempted to show is due to a 
deficiency and alteration of the normal secretion of the thyroid 
gland. 

(III) (a) Alteration of a physiological process without 
anatomical change:—(1) Amenorrhoea at adolescence; (2) 
Metrorrhagia at the climacteric. ( b ) Alteration with anatomical 
change :—(1) Gastro-intestinal glandular disease (not due to a 
specific germ as far as we know); (2) Heart, kidney disease, &c. 

From the classification of these morbid physical states, and 
from the fact that this train of symptoms occurred only when the 
diseases associated were not due to some specific microbe or extrinsic 
cause , it was possible to make the following enunciation, viz. 
that the morbid physical state of body met with was associated 


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1899.] 


BY E. S. PASMORE, M.D. 


73 


with excess, deficiency, or alteration of some normal constituent, 
or the disturbance of some physiological process essential to 
normal metabolism. I propose to comprehensively term these 
morbid states of body autotoxsemia, and the train of symptoms 
associated autotoxic insanity, or “ Deprimentia.” We may then 
define autotoxaemia as that morbid condition of body, not 
traceable to any external agent, but which is associated with 
excess, deficiency, or alteration of some constituent of, or the 
disturbance of some physiological process essential to, normal 
metabolism. The associated psychic phenomena of depression, 
temporary impairment of memory and hallucinations of hearing, 
and the subsequent progress of these symptoms, “Deprimentia.” 
This word, therefore, I should suggest should not have a vague 
general meaning as melancholia has had, but should be applied 
specifically to the train of symptoms such as I have described, 
associated with autotoxsemia. [Here the author related a series 
of cases.] 

I examined systematically 300 consecutive admissions, 100 
each of consecutive deaths and discharges, and 36 cases of the 
same physical states of body at various ages, with the accom¬ 
panying mental symptoms. 

Time will not permit me to enter into detail about these 
statistical examinations, but from them I have compiled seven 
tables of reference with the following heads : 

Table I. Showing physical and mental states in 100 cases 
of first attacks. II. Showing physical and mental states in 100 
recurring attacks. III. Showing physical and mental states in 
300 consecutive admissions. IV. Showing physical and men¬ 
tal states on admission in 100 discharges, in which officially no 
cause was assigned for the mental disorder. V. Showing 
physical and mental states on admission in 100 deaths. VI. 
Showing, in three sub-divisions of six each, the mental symptoms 
and physical states at various ages in first attacks. VII. 
Showing, in three sub-divisions of six each, the present and past 
mental symptoms and physical states. 

They all tend to show that with certain states of body 
certain trains of symptoms exist. 

Table I shows that in first attacks, with an autotoxaemic 
state of body such as I have described, one always gets the same 
train of symptoms. 

Table II shows that different mental states were recognisable 



74 OBSERVATIONS ON CLASSIFICATION OF INSANITY, [Jam, 

with different bodily states, and this was the case also in 
recurring attacks. 

Table III shows the same conditions as Table II. 

Table IV shows that in a great many of those discharged in 
which no cause could be assigned for the insanity, the physical 
state was one amenable to treatment, if not autotoxfcemic, alco¬ 
holic, or such like ; and that the train of symptoms corresponded 
with the physical states as shown in Tables I, II, and III. 

Table V shows that a great many of the deaths were in 
cases where the physical states were extremely grave and not 
amenable to treatment, or due to some acute intercurrent 
disease such as pneumonia. 

Table VI shows that at whatever age the same physical 
state occurred, the same mental symptoms were invariably 
present. 

Table VII shows that certain cases with certain physical 
states tended to run the same mental course. 

My reasons, then, for supposing that the train of symptoms 
such as I have detailed is intimately associated with and 
dependent on autotoxaemia as I have defined it are the fol¬ 
lowing :—(i) The mental symptoms improve, and in time 
altogether disappear and recovery takes place with an improve¬ 
ment or disappearance of the morbid bodily condition. (2) 
With recurring mental disorder the mental symptoms differ if 
the physical states differ; and this fact will account for the 
phenomenon which is often seen in asylums, several examples 
of which I have collected, of melancholia being cured by some 
intercurrent febrile disorder. (3) That if the mental disorder 
has been of some standing before the case has come under 
notice, and delusions of marked persecution have developed, 
showing a saturation of the brain with the products of auto- 
toxsemia, or if the physical state is one of great gravity, as 
diabetes, recovery seldom or never takes place. 

Dr. John Rose Bradford, F.R.S., in the course of his experi¬ 
ments on the pathology of the kidneys, some of which he dis¬ 
cussed in his Gulstonian Lectures this year at the Royal College 
of Physicians, found that after extirpation, wholly or partially, 
of the kidneys, nitrogenous extractives accumulated, not only 
in the muscles and organs, but also in the brain ; that in con¬ 
sequence of this accumulation the cortex cerebri becomes more 
irritable and more unstable. 


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189 9-1 


BY E. S. PASMORE, M.D. 


75 


He conclusively proved that the kidneys when sound had 
some controlling influence over the metabolism of the tissues of 
the body, that with weakening or loss of this controlling influence 
through disease nitrogenous extractives accumulated in all 
the organs and tissues of the body, including the brain, causing 
not only profound autotoxaemia, but also with this autotoxaemia 
increased irritability of the cortex cerebri. 

[The author here related a case which had lately come under 
his notice.] 

In this case we have the history of a woman ( 2 ) whose 
mental disorder seemingly at first was only of recent date, 
but on deeper investigation we find that she was really 
suffering from depression, for the past five years unrecognised. 
Running parallel we have a history of an abdominal growth, 
proving afterwards to be renal tumour, going on during the 
whole of this period, practically effecting a gradual nephrec¬ 
tomy ; then immediately after extirpation of the partially 
diseased organ—true nephrectomy,—the patient had a complete 
mental breakdown. Was the operation the cause of the insanity 
from shock ? What was and is the insane state ? Mental dis¬ 
order was certainly present before the operation, so that the 
shock of the latter could not possibly have been the real cause. 
The cause must have been certainly the gradual nephrectomy 
that was going on. So long as the condition was of insidious onset 
so long were the symptoms slow in progression, to be brought to 
a sudden head, i. e. a sudden increased nervous excitability, by 
complete nephrectomy. The results of clinical experience are 
thus in complete harmony with experimental facts. This dis¬ 
turbance of tissue metabolism which is true of the kidneys might 
be easily conceived to be equally true of all the other glandular 
organs of the body. 

Having, I trust, clearly shown then by experimental facts and 
clinical evidence that such a condition as “ Deprimentia,” as I have 
termed this mental derangement due to autotoxaemia, exists, it 
is only left for me to mention the other states of mental disorder 
which simulate it, and from which it is necessary to differen¬ 
tiate it. They are— 

(i) Onset of general paralysis; (2) Depressional stage of 
alcoholic insanity, and other allied states, morphia, &c. ; (3) 
Phthisical insanity; (4) Post-epileptic phenomena; (5) 
Hysteria; (6) Shock with acute stupor; (7) Post-febrile 



7 6 OBSERVATIONS ON CLASSIFICATION OF INSANITY, [Jan., 


depression ; (8) Cerebral tumour or abscess ; (9) Masturbatory 
insanity ; (10) Dementia pura ; (11) Puerperal melancholia ; 
(12) Insanity with syphilis ; (13) Feigned insanity ; (14) Reflex 
depression (?). 

Bearing in mind the fact that the present taxonomy of 
insanity is in a most unsatisfactory state, and that a classifica¬ 
tion ought to have for its main object the revealing of the 
causes of disease so as to render it serviceable for statistical 
registration, I shall suggest for future use the following nomen¬ 
clature, built up not only on clinical, but also on aetiological and 
pathological grounds. 

Main Classification : 

1. Autotoxic insanity. 

2. Exotoxic „ 

3. Epileptoid 

4. Degenerative „ 

5. Hysteroid „ 

6. Congenital „ 

7. Feigned 

1. Autotoxic Insanity or “ Deprimentia? —We may speak of 

(1) Diabetic deprimentia ; (2) Gouty deprimentia ; (3) Nephritic 
deprimentia ; (4) Catamenial deprimentia; (5) Cardiac deprir 
mentia. 

2. Exotoxic Insanity .— (i) Pathogenic. — (1) Infective 
insanity: (a) Insanity with or following the acute specific 
fevers ; (< b ) Puerperal mania (probably of pyaemic origin) ; (c) 
Acute delirious mania (specific ?); (2) Phthisical insanity ; (3) 
Syphilitic insanity ; (4) Gonorrhoeal insanity, mania of hydro¬ 
phobia. 

(ii) Toxinic.—(1) Alcoholic insanity ; (2) Metallic insanity 
(of lead, &c.) ; (3) Drug insanity (morphinomania, &c.). 

3. Epileptoid Insanity .—(1) Idiopathic epileptic insanity; 

(2) Hystero-epileptic insanity ; (3) Psycho-epileptic insanity : 
(a) Recurrent mania ; (< b ) So-called folie circulaire ; (c) Epi- 
lepsie larvee of the French. 

4. Degenerative Insanity .—(i) General paralysis and its 
varieties. 

(ii) Dementia pura (not symptomatic dementia, the terminal 
stage of most mental disorders).— (a) Senile changes: (1) 
Atheroma and its allied atrophic degenerations ; (2) Spino- 
cerebral pachymeningitis; ( 6 ) Gross lesions; (1) Tumour and 


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1899] 


BY E. S. PASMORE, M.D. 


77 


abscess (including gumma); (2) Traumatism ; (c) Idiopathic 
brain wasting; (d) Chronic progressive meningitis ; (e) 

Secondary to systemic nerve disease ; (1) Locomotor ataxy 
with mental symptoms, &c. 

5. Hysteroid Insanity .—(1) Hysteria gravis; (2) Moral 

insanity ; (3) Masturbatory insanity ; (4) Hypochondriasis and 
neurasthenia ; (5) Acute mental stupor, catalepsy, trance, 

ecstasy, &c. 

6. Congenital Insanity .—(1) Idiocy; (2) Imbecility; (3) 
Cretinism ; (4) Paranoia (a doubtful condition). 

7. Feigned Insanity (generally symptomatic only). 

Let us look at the classification from another point of view. 
So far back as 1876 Dr. Maudsley, in his Physiology of Mind, 
writes:—“Whatever be the real nature of mind, it is certainly 
dependent for its every manifestation on the brain and nervous 
system .” And all psychologists hold to-day that the actions 
which take place in the nerve-cells, however produced, are the 
physical concomitants of mind. Physiologists and histologists 
teach us that the nervous system is composed of elements— 
the neurons—each neuron an independent unit in itself, not 
united to, but influenced in some way by its adjacent fellow. 
Let us ask ourselves, then, what are the conditions that would 
affect this independent unit, the neuron ? They are—(1) 
Hereditary predisposition ; (2) Congenital defect ; (3) Arrest 
of development ; (4) Plasmic influences due to ( a ) Auto¬ 
toxic and ( b ) Exotoxic poisons ; (5) Degenerations caused by 
traumatism, growths, age, &c. ; (6) Innervation from adjacent 
neurons. 

It will be seen that if the actions in the upper neurons 
which are supposed to have a restraining influence on the lower 
neurons be the physical concomitants of mind, these actions 
will vary as the physical conditions of the neuron vary. 

We might divide these actions, then, into— 

(1) Congenital. 

(2) Autotoxic | plasmic 

(3) Exotoxic ) 

(4) Degenerative. 

The hereditary predisposition will account for the fact that 
some people go through life with all diseases and never become 
affected mentally, while others will break down early or late 
under the least indisposition and strain. 






























78 OBSERVATIONS ON CLASSIFICATION OF INSANITY. [Jan.. 

The conditions of arrest of development of the neuron and 
the power of innervation that adjacent nerve tissue has, might 
account for the other two divisions of the classification, viz. (5) 
Hysteroid, (6) Epileptoid, and finally we might add (7) Feigned. 

The minute histological pathology of how these conditions 
affect the neuron, and so pervert its psychic function, whether it 
be that the toxins of the body manufacture are not so potent 
as the toxins introduced from without ; whether the former 
only temporarily paralyse the neuron in whole or in part only 
of its structure, why we usually get recovery with cessation of 
autotoxaemia, or whether the latter destroy the neuron, and 
thus, as in states such as those due to alcohol and other 
exotoxins, we more frequently get complete amnesia and 
dementia eventually, it is not the province of my paper to-day 
to discuss. 

In conclusion I can only add that if it is possible to correlate 
mental disorder with bodily disease, it would be impossible to 
lose sight of such an important relation. In the early stages, 
when the disorder is more amenable to treatment than when it is 
fully developed, what good might be done. The great stum¬ 
bling block to the advance of alienism in the past has been its 
separation from the domain of general medicine. 

If the object of my paper to-day—the comparison of the 
correlation of the phenomena of mental disorder with the 
phenomena of bodily disease—has not been as fully proved 
as I should have liked, yet I shall rejoice if I have opened up 
only for discussion the subject of the mental taxonomy of 
to-day, a subject which in our speciality is in such an un¬ 
satisfactory state. 

(*) Read at the General Meeting, London, 12th May, 1898. (*) This patient 

made a complete recovery. This emphasises the fact that with the removal of the 
morbi causa the mental symptoms improve or disappear. The remaining kidney 
is probably healthy, and is now doing the work of both. 


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1899 -] 


THE WALDSTEIN CASE AT PRAGUE. 


79 


The Waldstein Case at Prague : Two Letters addressed 
to the Members of the Medico-Psychological Associa¬ 
tion of Great Britain and Ireland. By Professor Dr. 
Moriz Benedikt, Vienna. 


I. 

GENTLEMEN, —The Waldstein lawsuit has aroused painful 
surprise here, and the conduct of the psychologists taking part 
in it has evoked so much astonishment in professional circles, 
that it will be worth our while to subject it to a critical analysis 
—as follows : 

1. The relation of mental weakness to moral insanity. 

2. The danger of creating class legislation by a wrong con¬ 
ception of moral insanity. 

3. The question of bringing lunacy under State control. 

To make things clear I will recall to your recollection a 
certain lawsuit which took place at Vienna some time ago, 
which shows very clearly the danger of a stupid sense of justice 
springing up in certain sections of society. 

A certain Baron Ulm, between sixty and seventy years of 
age, settled a certain sum of money on one of the demi-monde 
(Windisch). The Baron's family would not recognise the debt, 
and—through one of those legal tricks which are only too 
common in Austria—Windisch was prosecuted for fraudulent 
solicitation, on the ground that she must have been cognizant 
of the Baron's mental weakness. 

As chief expert the late Professor of Psychology, Ludwig 
Schlager, stated his opinion that Windisch had formed this re¬ 
markably correct diagnosis, and the learned bench gave sentence 
in accordance with the medical evidence. According to Schlager, 
insanity is self-evident to an ordinary street arab ; and on the 
evidence of this specialist, a person was condemned after prose¬ 
cution in order that a family might be relieved of the payment 
of a just debt. 

The Waldstein lawsuit also owed its origin to a legal quibble 
used to substitute a criminal for a civil action. The Count 
Waldstein, deceased, hated his own family, and left the city of 
Vienna and certain friends amongst the municipal officials the 
bulk of his fortune. The offended relatives, and also apparently 









80 THE WALDSTEIN CASE AT PRAGUE, [Jan., 

the public prosecutor, came to this conclusion,—“ that a noble¬ 
man who wills away his property to the bourgeoisie cannot be 
right in his mind.” Physicians who had attended him, and par¬ 
ticularly the proprietor of a Viennese asylum, after examination, 
incautiously in open court declared him to have been insane. 

The first argument was that the young Count would never 
learn. There are insane persons who develop an extraordinary 
eagerness to learn, and sane children who will learn nothing. 
Temperament and sense of duty rule in this matter. Only the 
imbecile learn nothing from purely intellectual defects. Young 
Waldstein was a count, and in aristocratic circles the family 
tutor possesses neither the authority nor powers of discipline to 
curb a lively disposition or to stimulate a proper sense of duty. 
Secondly, there was his aversion to his mother. This was 
certainly a blot on the character of the son. But, as counsel 
for the defendants explained, the lawsuit itself vindicated the 
deceased intellectually. Thirdly, that the Count caused the 
lawyer to draft a letter to his agent. Whoever possesses any 
knowledge of business is aware that this proceeding. is recog¬ 
nised, even in the higher political circles of society, to be 
completely justifiable. 

As further evidence of imbecility it was alleged that the 
Count had described the Austrian Parliament as a “circus.” 
This expression is certainly disrespectful ; but, nevertheless, it 
is decidedly witty, for, from one year’s end to the other, do not 
our members of Parliament ride their several hobbies one 
against the other to the detriment of the country ? 

In quite a childish way the Prague psychologists employed 
in court “ went on the hunt ” to find out whether the Count 
allowed himself to be influenced, in order to draw therefrom 
conclusions of insanity. Maniacs cannot be influenced, nor 
those suffering from delusions, nor the completely deranged 
imbeciles, nor those whose ideas of morality have become 
warped. The weak-minded and obstinate are difficult to 
influence. 

The normal individual is, like “ clay in the hands of the 
potter,” influenced by education, literature, family surroundings, 
public life, &c. The higher phase of impressionability is most 
valuable in the sphere of thought, research, and creative intel¬ 
lect. Was Mozart weak-minded because he allowed himself to 
be influenced by Haydn and the Italians, or Raphael because 


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1899.] BY PROFESSOR MORIZ BENEDIKT. 8 I 

he permitted himself to be influenced by Perugino ? Are not 
judges influenced by the depositions and evidence of witnesses ? 
A psychologist might ascribe to the late Count odd caprice, but 
not waxen pliancy of will. It is incontestable that a woman, 
though of limited ability, has more psychological instinct than 
an average intelligent man. Further, it is a psychological fact 
that an intellectually gifted girl or woman may love a man not 
so endowed, though deserving of esteem for other reasons. 
But, up to the present, no sensible girl or woman has loved one 
bom weak-minded. No one doubts that Fraulein Pasqualine 
Metternich was an intellectual girl of the highest order, and it 
was stated on all sides, besides having been proved by her 
letters, that she was much attached to her fianct and husband. 

And how many psycho-pathological points of a technical 
nature had the cultured Princess Pauline Metternich oppor¬ 
tunity of observing ? So far from recognising him as insane, 
she welcomed him as her son-in-law with unfeigned joy. It 
is an undoubted fact that the deceased Count was an individual 
of average intellect, of amiable manners, with all the faults 
as well as all the privileges of humanity in his social rank of 
life. He knew how to manage his own affairs well, and how 
to protect himself against the repeated attacks of his family. 
His disposition was capable of enduring friendship or aver¬ 
sion, and therefore not weak. He was so energetic that he 
gave his antipathy (which for one of his position was unusual) 
to his own family practical shape in his will. 

Most assuredly the psycho-pathologists employed in this 
case were wrong in having disputed the testamentary ability 
of the deceased on the ground of insanity, and in stating 
that the defendants were able to recognise mental weakness, 
and had thus obtained money by fraud. The presiding judge, 
in his summing up, drew attention to the point that weakness 
of mind does not altogether disannul testamentary ability ; 
but this disclosure appears to have been made only at the 
last moment, otherwise the court would have been obliged to 
dismiss the case at the outset. 

It was generally thought surprising that psycho-pathologists 
had expressed the opinion that the defendants must have recog¬ 
nised insanity in the testator, whilst his most distinguished 
associates remarked no signs of it. If ministers, governors, 
diplomatists, generals, bankers, well-known advocates, and 

XLV. 6 







82 THE WALDSTEIN CASE AT PRAGUE, [Jan., 

notaries failed to notice it, how can it be scientifically main¬ 
tained that a difficult diagnosis like this could be affirmed by 
specialists ? 

We must recognise a serious deficiency in the culture or intel¬ 
lect of many psycho-pathologists ; they are no psychologists. 
Many of them have studied “ scientific ” psychology, but have 
not a real knowledge of human nature. 

True psychological knowledge is to be sought for in the ranks 
of poets, historians, teachers, and authors. So long as psycho¬ 
pathologists possess a merely superficial knowledge of human 
nature, so long will they incur the risk of describing human souls 
after their own fashion, and of stupidly regarding the sane as 
mentally unsound, and vice versd. 

Count Waldstein liked brandy, but only one witness—who 
did not belong to his household—had ever noticed anything 
of this. The rest of his acquaintances were astonished to learn 
it then for the first time. The Count neither drank in society 
nor was ever seen drunk. Does that constitute a tippler from 
a psychological point of view ? 

The Count had an enlarged liver, and succumbed to hepatic 
cachexia. The conjecture that the disease of the liver may 
have had some connection with the brandy is allowed, but is it 
proved ? 

As there were no other pronounced alcoholic symptoms 
except degeneration of the liver and its consequences, it is 
certainly not permissible to treat an invalid as a drunkard, or 
to come to a conclusion that any organ—one of which might, 
of course, be the brain—was diseased by alcohol alone. 

I hold that the decision of the Viennese psychologists, during 
the session of the College of medical men, was distinctly 
hazardous. And for this reason. It declared that if Count 
Waldstein had committed murder he would have been deemed 
irresponsible. Why should he have been unaccountable for his 
actions ? Because he tippled in secret ? Then at once throw 
open all the prison doors in the world ! For how many 
ordinary criminals are there in the world who not only tipple, 
but tipple often and secretly! 

As regards his mental weakness, that, as a rule, has no abso¬ 
lute reference to crime. The weak-minded may be homo nobilis 
as the most genial may be a bom criminal. There are cate¬ 
gories of criminals who are weak-minded—such as incendiaries, 


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1899.] BY PROFESSOR MORIZ BENEDIKT. 83 

—but they are not incendiaries because they are weak-minded. 
There are other psychical factors which must be considered, such 
as temperament and moral perception. All testimony which 
alleges insanity as an argument for wrong-doing must be looked 
upon as open to doubt from a scientific point of view. If the 
particular grade of intelligence cannot discern the material con¬ 
sequences of a criminal deed either to the criminal himself or to 
others, then it ranks as imbecility or some other brain trouble. 
But no one could ever be considered a born lunatic or eccentric 
who was qualified to be an officer, a crack sportsman, a correct 
steward in a position of trust, the successful suitor to a lady of 
position, the esteemed colleague of ministers, diplomatists, 
bankers, and distinguished lawyers. 

I recommend certain celebrated psychologists, as well as 
those who are yet unknown to fame, to read the articles of 
Grillparzer on “ Poor Spielmann,” from which they will gain a 
better insight into the connection of insanity with morality than 
they can obtain from their own text-books. 

II. 

I have long suffered some anxiety lest, owing to a certain 
prevalent haziness in scientific knowledge, a class legislation 
might be created, an evil which really already threatens us. 
For instance, if anyone belonging to the upper strata of society 
commits a crime or leads a dissipated life, detrimental to the 
interests of his family, the impression generally gains ground 
that a psychological inquiry should be instituted. Probably 
the result is that moral insanity as well as perhaps a low 
order of intelligence is diagnosed, and that testimony in favour 
of irresponsibility is declared. In legal circles particularly this 
has become quite an accepted modus operandi . 

The quarantine of the delinquent in a private asylum until 
the affair has blown over is then resolved upon. The indict¬ 
ment is thus shelved. Two years ago I communicated my 
fears to Baron von Krafft-Ebing, and represented that if psycho¬ 
pathologists were to study the question in prisons they would 
soon come to the conclusion that one must advance the same 
testimony in favour of the great majority of professional crimi¬ 
nals, and either let the whole crew loose on society or have 
them transported to asylums. 

I gained the impression, however, that I had not turned my 











































84 the waldstein CASE AT PRAGUE, [Jan., 

attention in the right direction. There are here the same 
conditions as in the question of hypnotism, where also looseness 
of criticism and practical skill opens gate and door to every 
folly, delusion, and eccentricity. I perceived that not in Vienna, 
but in some foreign country, I should find the solution of this 
intellectual and moral problem. 

First I tried Brussels, and the note of warning which I 
sounded there still tingles in the ears of psycho-pathologists 
and masters of forensic science. 

Where is the proper place for a person who, as we presume, 
suffers from an innate perversity of sexual instinct ? Does he 
deserve freedom? Certainly not. At liberty he is a social 
danger. Should he be in an asylum ? Certainly not. It may 
be that the individual in question is not only more highly 
gifted, but perhaps even more sensible than his medical or 
administrative protectors. The place for such a person is the 
house of correction, and in solitary confinement, for he is even 
more dangerous to his companions in prison than to those at 
liberty. For him we can have about the same sympathy as we 
might feel in shooting a favourite dog that had gone mad, to 
avert whose fate would be to inflict a wrong on mankind. 

Society rightly demands chastity, and punishes offenders by 
social means. Education and morality should raise the strength 
necessary to resist temptation. Penance as practised in the 
Christian middle ages, which has now become incomprehensible 
to us, had doubtless its origin in a wrong moral conception of 
sexual relations ; although we physicians advise no one to go 
into monastic seclusion, still we dare not pose as the advocates 
of unbridled licence. 

Now-a-days we have a new danger. I know that the publi¬ 
cation of obscene and criminal literature in popular form has 
caused you great annoyance. Your anger was what might be 
called “ gentlemanly ethical.” But such publications are dan¬ 
gerous from another point of view. When describing deliberate 
methodical seduction, the profligates pose as victims of an innate 
impulse, which is made the excuse for irresponsibility. Such 
arguments are plentiful on the stage of any European theatre, 
but from a literary or ethical standpoint they have no justifica¬ 
tion. An impartial judge would send these persons to prison, 
and sentence the selfish for a shorter period than the dangerous 
victim of an “ innate uncontrollable impulse.” 


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1899] 


BY PROFESSOR MORIZ BENEDIKT. 


85 


At the Antwerp Congress of 1890 I was present when Pro¬ 
fessor Jules Morel, of Ghent, made the remark, in private con¬ 
versation, to that celebrated lawyer and minister of justice, 
Mons. Le Jeune, that in Belgium perverse sexual excesses were 
increasing to an alarming extent. 

I told him that the police everywhere constitute a wall of 
protection between sexual delinquents and justice ; and for this 
reason, that these are frequently found amongst the higher ranks 
of society. If such an individual seeks another domicile, during 
the summer for instance, the particular police officials whom it 
may concern are duly informed, but the fact is not mentioned 
to the public prosecutor. It is not part of our duty to criticise 
this international custom here. Then in many places official 
medical examination is prescribed in order to prove the irre¬ 
sponsibility of the patient, and the troublesome one is either 
sent abroad for some weeks or “ towed into the port ” of a 
private asylum to find rest there. On this account it is now an 
urgent necessity to make the care of the insane a State question. 
I appeal to my colleagues not to misunderstand me, and think 
that such misdeeds multiply indefinitely. That which applies 
to offenders against morality applies to crime of all kinds. 

It is urgently to be hoped that the unfortunate expressions— 
moral insanity, folie morale\ and moralisches Irresein will disap¬ 
pear from the vocabulary of science. They are erroneous, and 
have misled physicians and jurists. So-called moral insanity is 
nothing but innate or acquired depravity (corruption), and 
represents, without further complication, no form of insanity. 
It is an altered physiological and anti-social condition which 
may be natural or acquired, but is not a disease ; and it should 
be specially noticed that under favourable development the 
natural or innate condition may remain latent. Such persons 
possess the full measure of intelligence to regulate their family 
and business affairs ; and, with the exception of the special 
aberration, to conduct themselves in a laudable manner. 

After the Eastern fashion we require to keep the three prin¬ 
cipal aims of penal law before us. The first and most important 
to determine is what, in the sense of social order, must be 
looked upon as right and what as wrong; the second is to 
render the offender harmless ; and the third is the possible 
reformation of the criminal. 

On these points physicians will surely agree, and will not 




86 THE WALDSTEIN CASE AT PRAGUE. [Jan., 

fall into a trap because the law everywhere speaks the perplex¬ 
ing language of moral-philosophical hypothesis. The physician 
will not wish to “vindicate.” To “vindicate” is the affair of 
the legislature and of the judge. 

In many countries it is first of all expedient to bring all the 
insane under the control of the State, in order to counteract 
existing abuses. I appreciate worthy men who own private 
asylums, and it is painful for me to offend many upright col¬ 
leagues by advancing my opinion. But that kind of uncon¬ 
trolled private enterprise leads to improprieties. I do not 
belong to the modem school of enthusiasts, who wish to bring 
everything under the control of the State, but with regard to 
insanity it must be urged that this is necessary. I could quote 
a long list of cases that have come under my notice to prove 
the necessity of State control, but on that point at least I shall 
keep silent as long as I am not compelled to speak out. 

In my personal experience as a medical man I have seen the 
prognosis for many perverts grow worse under the influence of 
narcotics for years, both as regards duration and cure, especially 
the melancholic and hysterical cases. 

At the Psychiatrical Congress at Antwerp (1885) I drew 
attention to this point in presence of our much honoured friend 
Hack Tuke. What a serious mistake for the patients it was to 
do away with the mechanical strait-waistcoat, and put in its 
place a dangerous toxic restraint! 

To control this convenient toxical strait-waistcoat in private 
asylums is a difficult matter, particularly in those countries 
where a feeling of leniency exists regarding abuses, and quite 
the reverse towards a positively tense sense of justice. It also 
happens that principals of public asylums are, for various 
reasons, enthusiastic empoisonneurs , ready to make use of every 
new drug; in public institutions, however, not only is control 
easier, but literary criticism better deals with blunders. 

Gentlemen, I have told you why I so highly value your 
esteem, and why I am a disciple of the British school,— 
because it demands that a scientist must first of all be a 
gentleman, not only in sentiment but in behaviour, doing right 
without regard to personal opportunity. I know that my “ call 
to arms ” against class legislation will find a powerful respon¬ 
sive echo on both sides of the Atlantic. But the official 
medical world in my native country does not appear to know 


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1 899.] AXIAL FIBRES IN THE BRAIN. 87 

that I speak with authority in the international world of psycho¬ 
pathologists ; and this coterie, strange though it may appear, 
has not only the ear but the arm of the law completely at its 
disposal. 


Further Research on the Formation of Axial Fibres in 
the Brain , by Dr. Paul Flechsig , Dr. Do liken, and 
Dr. Nissl. A Digest by W. W. Ireland, M.D., 
Mavisbush House, Polton. 

Dr. Flechsig. 

In a reprint from the Neurologisches Centralblatt , No. 21, 
1898, Dr. Paul Flechsig gives us some further investigations 
on the development of the fibres in the human brain. In his 
examinations he has used forty-eight hemispheres belonging to 
twenty-eight brains of all periods of early life, from the foetus 
of seven months to the child of fifteen months. He thus sums 
up the results to which he has arrived. 

1. The development of axis-cylinders in the lobes of the 
brain follows the same laws of growth and time of growth as in 
the spinal cord, the medulla, the cerebellum, and the middle 
brain. Flechsig observes in a note that the processes have a 
regular course, and not at random, as some observers have 
stated. This is owing to faulty preparations and inability to 
follow the complicated course of the nerve-fibres. 

2. It may be stated that nerve-fibres having the same 
functions get their axis-bands about the same time, whereas 
dissimilar systems have their own times. But it is to be borne 
in mind that collateral fibres attain their full growth later than 
those of the main stems. 

3. From which it follows that systems of fibres which are 
separated in their development by considerable intervals of time 
cannot fulfil the same special functions. As examples of this 
take the radiating fibres of the second parietal gyrus (29, 
Fig. 1) and the posterior median gyrus of about three months. 















88 


AXIAL FIBRES IN THE BRAIN, 


[Jan., 


4. The fundamental law comes out most clearly in premature 
births which have survived for some time ; for example, in the 
seven months* child who has lived for one or two months. In 
these cases the anatomical character of the nerve-fibres is more 
apparent than in embryos arrived at the full time. 

Dr. Flechsig*s previous inquiries had been made upon cases 
of early birth who had remained longer in life. 

These observations form the counterpart to Gudden’s experi¬ 
ments. The latter sought to destroy the sensory functions in 
new-born animals, and note the effects upon the development 
of the nerve paths of conduction. Flechsig found that the 
early function hastens growth, and this effect is more noticeable 
upon the sensory conducting or projection systems than upon 
the association systems. 

5. The new formations in the cerebral lobes begin from two 
and a half to three months before normal mature births. The 
first systems to appear are the radiation of the fillet, the 
olfactory tract, and the sensory conducting tracts. Scattered 
axial fibres do not occur in the cerebral lobes. The develop¬ 
ment of the axis-bands progresses in distinct places ; the inter¬ 
vening spaces are clear of these axis-bands. To hold that the 
association fibres are developed at the same time as the 
projection or conducting fibres is the result of faulty observa¬ 
tion. 

6. The cortex becomes developed in a great number of 
zones. Every tract is distinguished by the particular time in 
which its nerve-fibres are developed, and each has in its 
leading connections certain peculiarities ; the number of these 
fields is far greater then he at first recognised, the differentiation 
of the cortex is much finer, and distinctions in localisation are 
much more numerous. He now distinguishes forty fields of 
historical development, while before he could only make out 
nine (five sensory and four association centres). This increase 
is principally owing to a further dissection of the association 
centres and the discovery of two more sensory centres. The 
learned professor does not even think this number final ; more 
may yet be distinguished. These divisions are natural, not 
artificial; some of them represent special functions, as a glance at 
Figs. 1 and 2 will show. Field No. 1 covers Charcot’s motor 
zone; field No. 5 covers the visual sphere, as Vialet has 
rightly defined it. We cannot show that all these fields have 


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Fig. i represents the human brain on its outer aspect, Fig. 2 from within and 
below. The numbers denote the sequence in which the bundles of the 
axial fibres of the cortex appear in compact or loose form. The letters 
indicate special segments within the several fields, the significance of which 
will be further explained in my extended work. Nos. 26, 26 a, 26 b, form 
a single cortex field; likewise Nos. 33, 33 &e. 


To illustrate Dr. Ireland’s Paper. 


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1899] 


BY W. W. IRELAND, M.D. 


89 


special functions—are organs in the sense that Gall assigned to 
certain portions of the cortex. The number may appear to be 
suspiciously large ; but it must be observed that by far the 
most boundary lines which Figs. 1 and 2 represent are to be 
regarded as typical tracts of fibres in the foetus ; that is, as 
bounded tracts of fibres with axis-cylinders, and sometimes 
without any, which persist during a certain period of develop¬ 
ment. 

Dr. Flechsig divides the fields in the cortex into three 
groups : ( a ) Primordial areas, which are regularly formed before 
maturity (1—8, Figs. 1 and 2) ; ( b ) Intermediate areas, in which 
the axis-cylinders begin to be formed one month after normal 
birth (9—32) ; ( c ) Terminal areas, in which the axis-cylinders 
appear later than one month after birth (33—40). 

The primordial areas are comprised within the sensory 
centres of my former division. The terminal areas are all 
parts of my association centres. The intermediate areas 
belong partly to the sensory centres, partly to the association 
centres. The formation of the axis-cylinders in the terminal 
area in healthy growth begins in from four to four and a half 
months later than in the primordial area. Flechsig has observed 
the first axial fibres in the terminal areas at Nos. 38 to 40 in a 
child born at the full time, who had lived for seven weeks. 

The sensory centres are to be found in the primordial and 
secondary areas. In the first category are the median gyri, espe¬ 
cially the posterior ones, the lips of the calcarine fissure and 
the occipital convolution, the gyrus uncinatus, the internal 
orbital, the cornu ammonis and the subiculum, the gyrus for- 
nicatus, especially the middle third, and the cross convolutions 



of the parietal lobe. 

Within the terminal area I distinguish eight parts ; the first 
and second frontal gyri, the lower parietal gyrus, the second 
and third temporal gyri, and one piece of the gyrus fornicatus. 
These are the parts of the cortex by which the human brain is 
principally distinguished from the brains of the anthropoid 
apes. They also give the typical form to the human skull. 
The third frontal gyrus, however, does not belong to the ter¬ 
minal area. 

The intermediate areas are developed in a time between the 
primordial and the terminal. In the mature infant the axial 
fibres are already fully formed. The first developed intermedial 










90 


AXIAL FIBRES IN THE BRAIN, 


[Jan., 


areas are secondary sensory centres; the later ones he names 
the border zones of the sensory centres. These always adjoin 
the centre with which they are intimately related, but do not 
appear to have direct connection with other sense centres. 
Projection fibres come into these zones more scantily than to 
the sense centres, and are, as it appears to me, more irregular; 
the majority of them are of corticofugal nature. To the 
secondary sensory centres belong the foot of the first frontal 
(No. 9), the orbital portion of the third frontal (No. 10), the 
foot of the third frontal (No. 12), and the gyrus subangularis 
(No. 13). In the border zones are the posterior part of the 
first temporal, No. 23, and the anterior third, No. 21 ; also 29 
and 22. The development of the first frontal gyrus takes 
place in four periods ; of the third frontal in three. In the third 
frontal gyrus the pars triangularis is developed in its axis- 
bands at a different time from the pars orbitalis and opercu- 
laris; the pars triangularis belongs to the intermediate area 
which ripens late ; the pars orbitalis belongs to the primordial 
sensory centres. 

The development of the second parietal is in four fields. 
The first, a small secondary centre (No. 15), is in the opercu¬ 
lum, a posterior portion passing to the second occipital gyrus 
(No. 22), one adjoining the middle third of the posterior median 
which makes up the most part of the gyrus supra-marginalis 
(No. 29), and the lobulus parietalis (No. 39). Only the last is 
in the terminal areas. 

Nos. 22 and 29 are to be found in the gyrus angularis of 
the lower apes. In the anthropoids, judging by the naked eye, 
No. 29 is much more conspicuous ; 39, on the contrary, is either 
wanting or only rudimentary ; the bridging of field No. 22 to 
the middle part of the second temporal gyrus (partly a border 
of the auditory sphere No. 25), forms a spur (33), which I also 
miss in the brain of the anthropoids. This convolution fuses 
more or less with the gyrus subangularis and the first temporal 
gyrus in badly developed human brains. Flechsig adds in a 
note that in Helmholtz’s brain, Nos. 39 and 33 are markedly 
differentiated. Between the first temporal gyrus and the gyrus 
subangularis there are two distinctly separated convolutions, 
whilst in the badly developed brains hardly any of these con¬ 
volutions can be made out. The gyrus subangularis can be 
recognised through its peculiar construction in the chimpanzee. 


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BY W. W. IRELAND, M.D. 


91 


Nos. 33 and 39 are interesting pathologically as being in¬ 
volved in all cases of pure alexia without hemiopia. The 
professor supposes that the reason why monkeys cannot form 
a language, is that Nos. 33 and 39 are wanting in their brains. 

The precuneus is formed in four cortex fields, which are 
specified as Nos. 34, 26, 31. The insula is also developed in 
four fields. The primordial areas have an especial structure, 
so that a practised observer can distinguish sections from 
each of them. In the development of the fibres of one field 
the different categories develop in regular order, one after the 
other ; in one row of the field projection fibres begin their axis- 
bands, in another the association fibres do the same, so that one 
can already divide the fields into projection and association 
centres. In no case do the fibres of separate categories reach 
their full development at the same time. 

The direction of nervous conduction can be known with 
great certainty from the direction of development. The 
primary system of the primordial area develops from the lower 
cerebral ganglia towards the cortex. This is especially notice¬ 
able in the primary optic tract ; for example, in a child born 
from one and a half to two months too early, yet who has 
survived twelve days, axis-bands were only to be found between 
the outer corpora geniculata and the cortex. All primary sys¬ 
tems of the primordial area are from the direction of their 
development to be regarded as corticopetal. 

It is in the terminal area that, as a rule, the axis-bands first 
appear in the immediate neighbourhood of the cortex. The 
primary system also here takes the lead with corticofugal axial 
fibres. This is not the case with the projection fibres, which do 
not take a primary development, but only grow out of the 
cortical regions until the sensory, i. e. corticopetal, fibres have 
got their axis-bands. This also holds good with the fibres of 
the trabs, which are now only noticed in some sections. 

Though the order of development of the axial fibres gene¬ 
rally observes a given sequence, Dr. Flechsig has found impor¬ 
tant variations in different brains, some of which he specifies. 
Though in the majority of infants the fibres of the optic tract 
in the corona radiata receive the axis-bands sooner than the 
auditory tract, in an infant of eight months’ gestation who had 
survived birth there were found axis-bands in the auditory tract 
and none in the optic tract. Other variations are noticed in 


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92 AXIAL FIBRES IN THE BRAIN, [Jan., 


the growth of the fibres through the medulla, pons, and corpus 
striatum. 

Dr. Flechsig observes that with such variations it is in no way 
surprising that a bundle of fibres should be observed to take a 
different course from what he has described. 

In reply to the criticisms of his opponents, Flechsig observes 
that there are two separate questions. Do the centres which he 
describes exist ? and has he accurately defined their boundaries ? 
These boundaries he has several times had occasion to alter, and 
may do so again. He has now divided his old association 
centres into border-zones and middle fields, and he recognises 
that some of them are furnished with projection fibres, for 
example No. 15. He thus pursues his argument: the fibre 
systems in the greater part of my older association centres 
develop at least three months later than those of the sensory 
centres which belong to the primary group of the primordial 
sensory centres systems. Nerve-fibres which take their growth 
at such intervals of time can never have the same functions. 
As the function of a mass of grey matter is exclusively deter¬ 
mined through its relation to the paths of conduction, we may 
be sure that those portions of the grey matter which are con¬ 
nected with the tracts of nerve-fibres at such different times 
must have different functions. Dr. Flechsig tells us that it was 
in examining the growth of the fibres in the spinal cord and 
medulla oblongata that he gained confidence in the prevalence 
of the laws of development, and discerned that there are different 
regions in the brain. In his new terminology this view is thus 
stated : by the law of development the terminal regions of the 
brain must have quite a different relation to the whole organism 
from the primordial ones. He observes that he has succeeded 
in demonstrating paths of conduction from several sensory 
centres, for example from that of bodily sensation and the 
visual sphere in No. 39, and from the auditory and visual 
sphere in No. 38. He observes that the fasciculus longitudinalis 
inferior, upon whose nature as an association band the school of 
Wernicke base their notions of the structure of the brain, is 
partly a primary visual radiation and partly belongs to the 
projection system. Flechsig now holds that the cingulum, 
which he at first supposed to be a direct association system of 
several sensory spheres, mainly belongs to the projection system. 
He observes that the cingulum is well developed in the lower 


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1899.] 


BY W. W. IRELAND, M.D. 


93 


mammalia, in which we would scarcely look for extended 
association systems. The professor thinks that there is no 
choice either to assign the conjunction of the various sensory 
spheres to the thalamus opticus, or to several regions to the 
cortex which stand in connection with all or most of the sensory 
spheres. He observes that the optic thalamus is different from 
other internodes of the sensory conducting tracts like the 
corpora geniculata externa or the olfactory bulb. It is a much 
more complicated apparatus, which contains six parts, all dis¬ 
tinct in the time when the nerve-fibres acquire their axis-bands ; 
while other ganglia, for example the globus pallidus, are 
developed all at once. The nuclei of the fillet form only a 
small part of the thalamus, and many cortical fibres radiate into 
it which part into end branches, and lead from the cortex, as 
Kolliker has already pointed out. 

The direction of the development of the fibres issuing from 
No. 39 is a corticofugal one, from which we may guess that these 
fibres lead to the thalamus, especially as they do not join in 
with the connections of the nucleus of the fillet. Flechsig con¬ 
siders it an important question whether the associated im¬ 
pressions of the muscular sense with sight and feeling reach 
the cortex through the thalamus in distinction from the 
single excitation through the corpora geniculata, &c. 

Little stress can be laid upon the study of secondary 
degenerations where Flechsig’s topographical discoveries have 
not been at the same time borne in mind. 

In the text and in the notes the professor replies to his 
opponents, Monakow, Wernicke, Siemerling, Dejerine, and 
others, or denounces their descriptions of the histology of the 
brain as misleading. 

We do not reproduce those controversial passages, as the 
objections combated are rarely cited with sufficient detail to 
enable us to grasp their full import, nor have we access to most 
of the papers in which these criticisms are made. 

Against Monakow he urges that, as the Russian pathologist 
does not admit association centres he must spread the sensory 
centres over the whole superficies of the cortex, and divide the 
parietal lobe between the muscular sense and visual spheres. 
He has to strain the significance of pathological observations 
in order to make out that the gyrus angularis belongs to the 
visual sphere. As a proof of this Monakow gives out that 

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94 


AXIAL FIBRES IN THE BRAIN, 


[Jan., 


after destruction of the whole inner flat surfaces of both occipi¬ 
tal lobes, the maculae luteae still retain their functions, and that 
there is only a contraction of the field of vision, forgetting that 
in the cases which he cites in proof there are portions of my 
visual area still intact, viz. the cuneus, the gyrus lingualis, and 
the first occipital. After a still more simple fashion Monakow 
places the muscular sense in the parietal gyri. The fillet as 
the especial bearer of the muscular sense is assumed to spread 
out into the whole parietal lobe. As a proof of this he cites 
the case of Hosel-Flechsig, in which the upper fillet was almost 
totally degenerated, not because the posterior median convolu¬ 
tion was destroyed, but because the whole axial fibres of the 
parietal lobe were implicated ( Himpathologie , S. 260). Flech- 
sig adds: “As I myself have investigated this case and 
have preparations of it, I can certify that the parietal con¬ 
volutions did not show alterations up to as much as a half¬ 
centimetre on the anterior border.” Flechsig thus goes on : 
The upper fillet terminates solely in the central convolutions, 
though exceptionally in the upper and anterior portion of 
the first parietal. Disturbances of the muscular sense are 
generally found in lesions of the central gyri. Monakow 
acknowledges that the auditory sphere is confined to the first 
temporal gyrus, in view of the fact that there is no second¬ 
ary degeneration of the corpus geniculatum internum after 
disease of the second and third temporal and the occipito¬ 
temporal gyrus. In two brains which Flechsig has examined 
he found that the left auditory radiating tract betwen the 
corpora geniculata, the thalamus, and the cross convolutions of 
the temporal lobe, seemed to be twice as large as the right 
Further investigations may determine whether this observation 
furnishes a key to the use of the left auditory sphere for the 
acoustic apprehension of words. It so happened in both cases 
that the border zone No. 25 was provided with axis-bands on 
the left and not on the right. I have never observed marked 
asymmetries in the optic tracts. Considering the objections 
against the existence of the association centres with a small 
development of the projection system, Flechsig says that the 
great majority of observers base their views about the distribu¬ 
tion of the fibres of the brain upon sections coloured after 
Weigert’s method. These are principally sections of the brains 
of animals. The data are transferred to the brain of man with- 


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BY W. W. IRELAND, M.D. 


95 


out considering the differences, but an attentive examination of 
the brain of a rodent, for example of the marmot, has shown 
me that even in this brain there is not an equal distribution of 
the corona radiata in all parts. One finds between sensory 
centres rich in radiating fibres, sm’all areas which are distin¬ 
guished through their enormous richness of ganglion cells on 
the one hand, and through the almost entire want of radiating 
fibres on the other. Here the cells are much more abundant 
than anywhere else, and each of these areas is through intra- 
cortical association fibres connected with at least two sensory 
centres. This also goes to show that the cortex is not of the 
same structure throughout. 

Flechsig states that he possesses sections of the brains of 
dogs and rabbits coloured by methylene blue, which clearly 
show that even in these animals the cortex is not all of one 
pattern. 

Dr. Dollken. (*) 

At the end of Professor Flechsig’s communication, Dr. Dollken 
states that he examined forty-five complete sections which he 
made in frontal, horizontal, or sagittal directions through the 
brains of dogs and cats. The sections were coloured after 
the Weigert-Pal method. The brains examined were from new¬ 
born animals to thirty-five days old, two months, three months, 
and full grown. He found in the brains of these animals a 
successive development of the axis-cylinders in the paths of 
conduction. Axis-bands were not found to occur either soli- 
lary or scattered ; but it was constantly observed that the axis- 
bands took their growth in bundles or layers. Before the fifth 
or ninth day he could observe no axial fibres in brains of 
these animals ; but after the ninth day the axis-bands were seen 
in the cat's brain in the following structures : 

1. Bundles from the inner capsule to the gyrus coronalis and 
the gyrus cruciatus, anterior and posterior, representing the 
median convolutions in the human brain. 

2. Tractus olfactorius. 

3. Fornix longus. 

4. The upper part of the commissure of the cornu ammonis. 

5. A layer of the cornu ammonis passing into the gyrus 
hippocampi (a part of the alveus). 

After ten or eleven days axial fibres were observed— 

e 


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96 


AXIAL FIBRES IN THE BRAIN 


[Jan., 


6. In a part of the cingulum. 

7. A thin bundle from the inner capsule to the gyrus 
ectosylvius posterior. 

8. The anterior portion of the fourth and third gyrus 
arcuatus. 

On the thirteenth and fourteenth days axial bands were ob¬ 
served— 

9. In a small layer in the middle part of the gyrus margin¬ 
alis. 

10. In a bundle from the inner capsule into the gyrus 
ectosylvius posterior. 

After fifteen or sixteen days axial bands were formed in— 

11. A bundle from the corpus geniculatum externum to the 
posterior part of the gyrus marginalis and the gyrus post- 
splenialis. 

On the nineteenth day begin to become mature— 

12. The middle third of the trabs. 

13. The dark portion of the anterior commissure. 



Schema des Hundegehirns. 

sy. Fossa Sylvii. pr. Fissura praesylvia. cr. Fissura cruciata. ot. Fissura 
occipito-temporalis. gen . Fissura genualis. 1. Gyrus coronal is. 2. Gyrus 
cruciatus posterior. 3. Gyrus cruciatus anterior, o. Lobus olfactorius. 
s. Gyrus sylviacus (ant. u. post.) 1. Gyrus arcuatus. e. Gyrus ecto¬ 
sylvius. ss. Gyrus suprasylvius. m. Gyrus marginalis. pro. Prorea. 
cc. Corpus callosum, f. Gyrus fornicatus. h. Gyrus hippocampi, u. 
Uncus. sp. Gyrus splenialis. pr.sp. Gyrus praesplenialis. ssp. Gyrus 
suprasplenialis. spp. Gyrus postsplenialis. 


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1899] 


BY W. W. IRELAND, M.D. 


97 


In the dog on the ninth day there is nothing in the brain 
having axial fibres save the gyrus coronalis, the gyrus cruciatus, 
anterior and posterior, and the path leading to them from the 
inner capsule. 

The histological development of the fornix longus begins at 
the eleventh or twelfth day; it also begins in the upper part 
of the commissure of the hippocampus ; in a path from the 
inner capsule to the posterior and under portion of the gyrus 
marginalis and in the upper part of the fourth and third gyrus 
arcuatus. On the fourteenth day bundles appear which pass 
from the corpus geniculatum externum into the gyrus margin¬ 
alis and post-splenialis. 

From the seventeenth to the twentieth day are provided with 
axis-bands the middle third of the trabs, and somewhat later 
the anterior third of this structure. The fibres of the trabs 
mostly issue from the middle side of the prorea, from the gyrus 
cruciatus, anterior and posterior, and from the gyrus coronalis. 

The development of the axis-bands in the dog is generally 
one or two days after analogous parts in the cat, but the order 
and sequence are the same. The bundles mentioned can be 
easily traced. The association fibres obtain their axis-bands 
between two convolutions from the eighteenth to the twentieth 
day in one part of the sphere of bodily sensation, gyrus coronalis, 
&c., and perhaps about the same time in the optic tract. In 
animals destitute of convolutions, like the rabbit, the rat, the 
mouse, and the guinea-pig, the development of the axial fibres 
takes a similar order though a different time. In dogs and cats 
the nerve-fibres in some of their brains are fully developed two 
or three days earlier than in other animals of the same species. 

From the eighth to the eighteenth day there are only seen 
isolated systems of fibres ip the brain, and they obtain maturity 
in bundles as far as I can ascertain, always in the same order. 

Dr. Nissl. 

It is apparent from Flechsig’s own papers that the publica¬ 
tion of his views has aroused considerable opposition in 
Germany, and this will not be lessened now that instead of 
nine he claims forty cortex fields, the development of which he 
has made out. Flechsig’s leading idea is that in watching the 
development of the axial nerve-fibres he has found a key to the 
functions of the brain, and that by observing the connections of 
XLV. le 



98 


AXIAL FIBRES IN THE BRAIN. 


[Jan., 


the different masses of grey matter he may guess what special 
functions they also perform. To make a thoroughgoing 
criticism of his investigations one would require to follow his 
dissections on the brains of infants, and this is not easy. 
Trusting to his methods, the professor goes far ahead of clinical 
and pathological observations, which he assumes will follow 
after. Naturally it is easier to criticise his inferences than his 
facts. 

In a paper in the Monatsschrift fur Psychiatrie und 
Neurologie , Bd. iii, Heft 2, Dr. Franz Nissl remarks, “ I have 
convinced myself of the impossibility of giving in short and 
clear terms a sketch of Flechsig’s Psychiatry in Gehim und 
Seele. I can subscribe to every word of Sachs when he says 
what Flechsig brings forward as psychological and psychiatric 
inferences is in part so superficial, in part so obscure, that there 
is no gain in considering it. There is such a confusion of all 
possible things that to try to arrange them would be more 
difficult than to follow his anatomical data.” 

For myself I may say that it is sometimes not easy to reach 
Flechsig’s meaning; but I should not have taken so much 
trouble to render his observations into English unless I had 
believed that they contained something of value. In vigorous 
terms Nissl objects to the assumptions of the learned professor 
of Leipzig, and seems especially dissatisfied with his two 
separate “ think-organs,” the one in the front brain, the seat of 
the feeling of personality, the other behind, the seat of mental 
productivity. He observes that Flechsig assigns this rdle to 
the front brain for no better reason than that he finds the area 
in question in close relation with the olfactory sphere and the 
sphere of bodily sensation. Nissl denies that in general 
paralysis those parts containing the think-organs are especially 
affected. He questions the correctness of Flechsig’s observa¬ 
tion on the finer structure of the cortex, and promises to show 
in another place evidence for this condemnation. He observes 
that had Flechsig studied the cortex with the elective method 
of examining the nerve-cells, he would have avoided some 
errors. Had he done so he would have recognised the motor 
cells in the well-defined area of the so-called motor centre as of 
the same kind as the cells in the spinal cord of man, of the 
frog, and of the lizard ; he would not have spoken of the 
granular layers in the visual sphere, still less have compared 


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1899 .] 


CLINICAL NOTES AND CASES. 


99 


them with the granular layers in the retina. Nissl observes 
that while Flechsig gives sharp boundaries to his localisations 
on the surface brain, he might have noticed that the different 
layers in no way trouble themselves about his boundaries. 

(}) The Mature Development of the Conducting Nerve-paths in the Brain of 
Animals (a preliminary communication). By Dr. D6llken, Assistant Physician to 
the Clinique for Nervous Diseases in the University of Leipzig. 


Clinical Notes and Cases. 


A Case of Juvenile General Paralysis . By A. Helen 
Boyle, M.D., Brighton. 

C. V—, aet. 19, was admitted into Claybury Asylum on 21st 
December, 1894. 

On admission, childish, undeveloped, skin pale and greasy, 
dark straight hair, and brown eyes. Height was 4 ft. 
10 in. ; weight 8 stone. She was well nourished, though not 
fat. Slight mammary development. Palate very high and 
narrow. Enamel of teeth lined transversely. General shape 
good. When she spoke, which was rarely and not spon¬ 
taneously, there was hesitation and drawling. Her gait was 
shambling, and she dragged her feet, being liable to trip. 
The knee-jerks exaggerated; pupils regular, and reaction 
normal. 

Mentally she had an imbecile appearance, and was simple and 
childish in manner. “ She is very confused, stupid, and can 
hardly be got to answer questions at all. She does not know 
how long she has been here, but can count and multiply simple 
numbers. She cannot tell what day it is without long thought, 
and takes very little notice of what goes on around her. 
Emotionally she is indifferent and placid rather than happy 
when left alone, but when interfered with she is spiteful, and 
now and then screams at the top of her voice, though as a rule 
quiet (possibly this may be from headaches). She has no 
delusions as far as can be made out. 

The past history as got from her parents is that she was 
healthy as a baby, had no rash except measles, and never 

had anything wrong with her eyes, ^be got 4>Yff teething 

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CLINICAL NOTES AND CASES. 


U an., 


well, with the help of teething powders, and had no convulsions. 
At school she seemed fairly bright and cheerful. About 
fourteen or so she left school, and took a place as a servant, 
where she was worked hard and only stayed three months, 
leaving because she felt overdone. Soon after she took another 
place, and in four months became ill, was dull, and could not 
walk as well as usual, and came home. When at home she had 
a fit (aged sixteen), after which she was in bed, and had to be 
taken to the infirmary, where she was kept about four or five 
weeks. 

Subsequently her walking and her dulness became worse. 
She complained a good deal at times of pain in her left arm, 
which she used to rub, and also of some difficulty in swallowing. 
Her speech was noticed to be peculiar about one year before 
admission, /. e . at eighteen. Her character was quite altered, 
she became sullen and lazy, stayed constantly in bed, and took 
no notice of anything. Her habits were indifferent, and at last 
her parents were obliged to send her back to the infirmary, and 
she then came on to the asylum. She was always a steady girl, 
and had no worry as far as her mother knows. She had never 
menstruated at all. 

The family history is as follows : 

A grandfather and two uncles died of “ consumption.” 

The father, who is alternately coster and gas-worker, is said 
to take too much alcohol at times, but I could get no real 
history of alcoholism. His wife, whom I saw alone, assured me 
that, although she had seen him the worse for drink on rare 
occasions “ when out for a spree,” as a rule he was quite steady 
and had never been “ gay ” in any way. Moreover, the home 
is tidy and comfortable, and he himself a spare, athletic, healthy- 
looking man, who is “ never ill.” 

The mother, a charwoman, looks robust, and says she has 
never had a day’s illness that she can remember except her 
confinements, and that they were always easy and natural, with 
no trouble afterwards. 

No history of syphilis in either parent was got, nor any of 
nervous trouble. The mother had ten pregnancies, all full-term, 
and no miscarriages. But—first pregnancy, the baby died in 
a week or so of birth, cause unknown ; second pregnancy, the 
baby died within six weeks of birth, cause also unknown ; 
third pregnancy was the patient; fourth pregnancy, a girl now 


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1899] 


CLINICAL NOTES AND CASES. 


IOI 


twenty-one, in service, and healthy. The other six are all alive 
and well. The mother states that their teeth are good as far 
as she knows, that none of them have suffered from any nervous 
trouble, but only ordinary childish ailments. There are in all 
nine girls and one boy. 

History of Case .—During the first five months there was 
no special note. She became somewhat worse, suffered from 
frequent headaches, and her habits were bad, the bladder acting 
often, and the rectum occasionally, without her being apparently 
conscious of the fact. 

In June, the sixth month of her stay, she had her first 
seizure since admission, and in the early part of July two 
more. They were slight, more like “ sensations,” as the nurses 
say, but were succeeded by a stuporose condition, and the 
patient had to lie down for a long time after them. There 
was little or no spasmodic movement. Her habits during June 
and July, when she had these attacks, were very considerably 
improved as regards the bladder and the rectum, compared 
with the preceding period of freedom from these seizures. 
Her mental condition during this time remained much as 
above described, possibly more dull and vacant. She stood 
almost invariably at one spot on being left by the nurse. 

On July 27th patient had a severe seizure. She was quite 
comatose, with flushed face, dilated pupils, which were equal 
and insensitive to light. The pulse was 120, full and bound¬ 
ing, and the temp. 104*2°. There was some twitching of the 
muscles on the left side, both limbs and face, and apparent 
paralysis of the right side, with some general rigidity. Knee- 
jerks were exaggerated. There was also retention of urine, 
and the catheter had to be used. The bowels were consti¬ 
pated, and an enema given. 

28th.—Next day the temperature rose to 104*8° ; there was 
still retention of urine and constipation. Calomel given. 

29th.—Patient began to menstruate for the first time, but 
scantily. Her temperature began to come down, the pulse was 
88, respirations 24, the paralysis less complete, and the coma was 
going off. There were red marks from vaso-motor dilatation on 
all points of pressure; nothing abnormal found in the chest. 
Bowels moved five times. 

31 st.—She can draw up the right foot, but does not move 
the right hand or arm. She is more conscious. Temp. ioo*6°. 


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102 CLINICAL NOTES AND CASES. [Jan., 


August ist—Better. Pulse 96, resp. 18, temp. 99*8°. Has 
stopped menstruating. 

2nd.—Consciousness is returning, and for the first time the 
pupils are reported unequal, the right being larger than the left 

4th.—Patient is not so well, groaning slightly, duller again. 
Breathing is shallow and hurried, with well-marked friction 
sounds at the base of the left lung. 

From this date she became steadily worse. Right lung affected 
at base. Temperature higher. Difficulty in swallowing. Became 
unconscious again, and died on August 10th. 

Post-mortem Examination .—General paralysis evident. 

Skull thick and dense, and dura mater very firmly adherent 
over the whole surface. Dura mater much thickened. Superior 
longitudinal sinus dilated. Pia arachnoid much thickened and 
adherent to the convolutions, especially over the frontal region. 
When stripped off it leaves the appearance of a worm-eaten 
surface. Cerebro-spinal fluid is opaque, and in great excess. 
Cerebrum badly developed and small. Grey matter fair in 
amount, gelatinous in appearance. White matter much con¬ 
gested. Lateral ventricles dilated, and floor granular in places. 
Basal ganglia normal. Cerebellum normal. Fourth ventricle 
very granular all over. 

Spinal cord much congested. 

Heart small, with pale muscle and ante-mortem clot in the 
right side. Valves normal. 

Lungs not adherent to the chest wall, but in the lower lobes 
of both at the posterior extremity there was an infarct, that on 
the left side being the larger and measuring 2 \ inches at its 
base, that on the right 1 inch. The rest of the lungs was con¬ 
gested. The liver, spleen, and kidneys were normal. 

I direct your attention to the following points of interest: 

1. The age of the patient. She began to show signs of the 
illness at about fourteen or soon after. Although there has 
been a certain number recorded as beginning at or near puberty, 
these are still uncommon compared with the immense number 
of adult cases. I have looked through the case-books at the 
Claybury Asylum, and find that there have been three female 
deaths due to general paralysis, in whom nervous symptoms 
began about the time of puberty, and a fourth who died at 
the age of twenty, the history being very short. 

2. The causation is very obscure. Phthisis in the family 


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history possibly predisposes to mental trouble. The only 
other possibility is congenital syphilis, which, in absence of 
definite history, is suggested by the fact of the first and second 
of the family dying very soon after birth, the second living just 
a little longer than the first ; no recurrence of similar incidents 
throughout a large family, and also that the patient’s teeth had 
imperfect enamel, though this again may be explained by the 
teething powders which she had, and which may have been 
mercurial. There is no traumatic or nervous history, no worry 
or real overwork. 

3. The relation between the incontinence of urine and faeces 
and the seizures, her habits in this respect improving during the 
months she had the attacks. 

4. The apparently intimate connection between pubescence 
and illness. 

The symptoms of general paralysis supervened at the most 
usual time for the appearance of menstruation, which in her 
case was then absent. The first signs of the catamenia were 
ushered in by a severe convulsive attack, which was thereafter 
relieved and partially recovered from as soon as the period 
began, although she died a few days later. Out of five cases 
of juvenile general paralysis in females recorded by Dr. 
Wiglesworth and Dr. Clouston, four of them never menstruated 
at all, and the fifth either not at all or scantily. In only four 
of a total number of twenty-nine girls suffering from this malady 
was it recorded as having occurred, and then only before, not 
during the course of the disease. 

Metabolism at puberty is certainly profoundly affected by 
ovarian activity, which, with the prospect of pregnancy, results 
in a habit of producing material not required for celibate life, 
and probably even deleterious. This may be excreted normally 
as the catamenia. Under the conditions of pregnancy this 
material is retained or, one might say perhaps more truly, 
excreted in another way, being required for the growth and 
development of the foetus. 

If one may put it thus, the ovary has several functions—to 
produce ovules, to modify metabolism, to excrete what is not 
required, directly or indirectly. 

These last two functions are probably carried out by reflex 
nervous action, and possibly also by an internal secretion, for 
ovarian substance is said to be a powerful drug (causing rise of 

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104 CLINICAL NOTES AND CASES. [Jan., 

temperature), acting in chlorosis as an emmenagogue and 
increasing the haemoglobin and red corpuscles in the blood, and 
the theory advanced for its use is that chlorosis is a neurosis 
acting through changes in the internal secretion of the ovary. 
I suggest that it is possible in the case of this patient that the 
constitutional taints modified the ovarian secretion so that a 
toxaemia occurred, either owing to the altered secretion itself 
or some by-product of the altered nutrition which should have 
been excreted in the usual way. In the fact that to the end 
the general nutrition was fairly good this patient differed from 
most of the recorded cases, in which emaciation was very 
marked. 


Discussion 

At the General Meeting, London, 13th October, 1898. 

Dr. Robert Jones. —I should like to know whether in the opinion of the members 
of the Society we should look upon general paralysis as an entity, as a type of dis¬ 
ease. Is it a type of general disease ? We know that there are two things that go 
with it, the paresis and dementia, but it seems to me to vary much. These juvenile 
cases are not very much like ordinary general paralytics. In ordinary cases we 
find the exaltation and paresis; but in these cases, as Dr. Boyle has suggested, 
although the children are bright at school they seem to become very dull and 
depressed. I myself was a little time ago very sceptical as to the syphilitic origin 
of general paralysis; but I must say I am becoming very gradually, and none the 
less very thoroughly, converted to the theory that syphilis and general paralysis go 
very much together. I* have seen at Claybury several cases of juvenile general 
paralysis, but this is the most interesting we have had recorded. At puberty there 
is general stress upon the organism, an organism perhaps tried by constitutional 
decay owing to inherited syphilis, and also by the actual poison that must be 
circulating in that person’s body. And if we look upon the pathology of general 
paralysis, it seems to limit itself more or less—much more than less—to the 
association fibres of the neuron. When do these fibres appear? They receive an 
undue stress about the period of puberty or adult age; but it is extraordinary that 
we find so very few cases of general paralysis in young people, and in those we do 
meet with there is, as a rule, some sort of inherited syphilis. With regard to the 
pupils, I should like to know whether there is any one definite symptom of general 
paralysis in them. I think, from a fair experience, that the speech seems to be the 
most pathognomonic; others would say perhaps fixation of pupil, as in locomotor 
ataxia. In Dr. Boyle’s case it was this paralytic mydriasis that was the more 
marked, not fixity of accommodation. The vaso-motor dilatations are also inter¬ 
esting. If general paralysis is not an entity, is it a genus with a number of species ? 
Does it include saturnine, syphilitic, and alcoholic general paralysis? In some 
cases of general paralysis, with the ordinary signs of the disease, there is found 
nothing but syphilitic artentis. I think the earliest age at which syphilitic endar¬ 
teritis was found was described by Dr. Barlow, and that was a few weeks after birth. 
As to the metabolism at puberty, what Dr. Boyle has told us is very interesting; 
but the influence of the ovary is a speculative matter I am not capable of discussing. 

Dr. Mickle. —I had the disadvantage of not hearing the first part of the paper; 
but speaking on the general subject of general paralysis in youn^ persons, in this 
case it appears to have been one of the kind sometimes called juvenile or pube¬ 
scent general paralysis. The chief interest in these cases is partly etiological and 
partly clinical. The strongest etiological relationship appears to be syphilitic. A 
traumatic element has been reported in some cases. But regarding the clinical 
aspect of the majority of the cases, one finds certain departures from the general 


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paralysis as usually observed in adults, especially as regards one point, viz. the inci¬ 
dence in the two sexes. In adult general paralysis the frequency is several times 
greater in the male than in the female. On the other hand, in juvenile cases the rela¬ 
tive frequency is about equally divided between male and female. The average 
duration of the disease is longer among voung persons than among adults. Then 
the exalted delusions so often found in adults are comparatively rare and slight in 
the young. As regards the physical symptoms of the disease, I do not see how on 
the whole there can be very much difference between the young and the adult. 
There are certain seizures to which general paralytics are subject, which are quite 
as frequent, if not more, in the young than in the adult. I have especially noticed 
in a few cases of general paralysis occurring in early youth the tremor about the 
muscles of the face. One great authority on the subject holds that to be a strong 
indication of alcohol having a large, perhaps the chief, share in the etiology. I 
have, however, seen a number of cases which completely oppose that view. And I 
remember two young paralytics showing a large amount of tremor, with no evidence 
whatever of their having had any alcohol. With regard to the cerebral post¬ 
mortem appearances, there is practically no difference between juveniles and adults 
when the length of the disease is considered. There are a number of cases of 
juvenile general paralysis recorded and unmistakeably described by observers who 
have long ago gone to their rest. I do not think that there is any age when in¬ 
dividuals are free from the disease. I believe in an infantile general paralysis, and 
see no reason why a child should not be a general paralytic at its birth. It is diffi¬ 
cult to prove that; but if we examine the history of the recognition of general 
paralysis one has very fair grounds for believing that to be probably true. I think 
that among those who have been described as dying in early life from congenital 
syphilis with lesions of brain and cord, many were general paralytics. 

Dr. Mercier. —I rise not to traverse the whole field of etiology, symptomatology, 
pathology, and treatment of general paralysis, which might occupy us to an incon¬ 
venient hour, but to welcome the first paper before this Association by a lady 
member, and to express my high appreciation of that paper. I noted that this 
patient improved very much after a convulsion. Now I think it is a common 
experience that general paralytics do always improve temporarily after convulsions. 
If a patient is having convulsions at stated intervals, after any convulsion his con¬ 
dition will be decidedly better than it was immediately before the convulsion, but 
not so good as immediately after the previous one, and so he will go on deterio¬ 
rating, but not steadily. He will pursue a course which may be compared to a 
switch-back. Every fall will be deeper than the previous, and every rise will be less 
high, until he arrives at his destination. 

Dr. Boyle. —In reply to Dr. Jones, and as I ventured to suggest the occurrence 
of toxaemia, it has been said that the differences in the course of general paralysis 
in various cases are due to the differences in the toxins producing the disease. 


The Effects of an Injury to the Head in an Alcoholic 
Subject . By Nathan Raw, M.D., Medical Superin¬ 
tendent, Mill Road Infirmary, Liverpool. 

The following remarkable case exemplifies in a marked 
manner the varying symptoms which may be produced in a 
subject of chronic alcoholism, and especially when some severe 
injury to the head has occurred to mask and complicate them. 

H. P—, aet. 38, a window cleaner, was admitted into this 
Infirmary on 13th December, 1897, with a strongly alcoholic 
history. Two days ago he was working on a ladder, whence 

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CLINICAL NOTES AND CASES. 


[Jan., 


he fell a distance of eight feet, alighting on his head. He was 
found by the police, who thought him drunk (which he probably 
was) and removed him to the lock-up, where he spent the night. 
He remained there twenty-four hours, when he was bailed out, 
and after removal home he was found to be semi-conscious and 
dazed. During the night, for the first time in his life, he had 
fourteen fits of an epileptic nature. 

On admission here the next day he was carefully examined, 
more especially with regard to the cranial injury. He has an 
intelligent appearance, head almost bald, is very slow in per¬ 
ception, and only answers questions after considerable hesitation. 
Ideation imperfect. He gives in his own way a rational 
account of himself, and persists in the statement that he was 
quite sober when he fell, but remembers nothing afterwards 
until he was taken home. 

On examination there was a large general bruise and haema- 
toma over the right side of his head, exactly corresponding to 
the motor area in situation. No wound, and no traces of 
haemorrhage nor other sign of fracture of skull. His muscular 
sense was good ; no paresis of opposite side or facial paralysis. 
Reflexes normal, optic discs normal, and pupils normal. He 
was diagnosed as a case of probable concussion of the brain, 
and kept in bed on milk diet. He progressed well for two 
days, and I thought that he was improving, when without any 
prodromal symptoms he developed fits and had thirty-nine in 
rapid succession during the night. The fits were epileptic in 
character, chiefly confined to the left side, and invariably com¬ 
menced in the left thumb and hand, rapidly spreading to arm 
and face and then to left leg, afterwards becoming general all 
over the body. In fact, to briefly describe the convulsions I 
would say they corresponded to an irritative lesion of the right 
motor area (cortical). Two hours after the fits ceased he was 
quite conscious, but it was noticed that he had complete left 
hemiplegia. The left arm and leg were completely paralysed, 
with marked lowering of temperature ; the facial paralysis was 
only partial, involving only the lower portion of the nerve. The 
orbicularis oculi and the frontal muscles were not involved. 
The tongue deviated to the paralysed side. The optic discs 
were quite normal. A special nurse was appointed to watch 
and note his symptoms, and in two hours she called the medical 
official, informing him that the paralysis had passed off as 


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CLINICAL NOTES AND CASES. 


107 


rapidly as it came. I saw the patient at once, and assured 
myself that he had no sign of paralysis, his muscular power 
being the same on both sides. He was quite conscious. 

December 16th.—To-day he has had several minor fits, in 
each case losing consciousness for a few moments. 

17th.—To-day he has had nineteen severe fits, each one 
lasting five minutes and being quite distinct and epileptiform in 
character. He has again after the fits complete left hemiplegia. 

The question of operation now naturally arose, and as the 
man was becoming exhausted it was thought desirable to do 
something. 

All his symptoms pointed to an irritative lesion of the cortex 
on the right side, corresponding to the bruise, but the important 
fact that his paralysis was transient, and had completely passed 
away, led me to believe that there might be some cortical 
laceration with haemorrhage—that there was no lesion which 
could be removed by operation. 

18th.—Next day he had again fourteen fits of a very severe 
type, and immediately afterwards he again developed complete 
hemiplegia, which passed away in four hours. 

20th.—He remained well for twenty-four hours, when he was 
again suddenly attacked with a most violent epileptic seizure 
and complete unconsciousness for ten minutes. After this fit his 
hand and leg were weak, but not completely paralysed ; no 
hemianaesthesia. His mental condition was confused ; he was 
continually asking for his clothes and whisky. 

22nd.—To-day he had two more powerful fits, leaving him 
confused, very irritable, and difficult to deal with and to keep 
in bed ; no paralysis, but slight paresis. 

23 rd.—Again had a severe fit, in fact the worst and longest 
since admission. Immediately after this fit had ceased he 
developed complete left hemiplegia, which lasted for two hours, 
and then passed off as rapidly as it came. 

24th.—Is much better, eats and sleeps well, not so confused 
or irritable, can converse fairly rationally, but his perception is 
still slow; memory deficient. From this time he improved 
rapidly. His mental symptoms cleared up, and he was allowed 
up. 

He was most anxious to get home, evidently to be in time 
for the Christmas festivities, and he went home perfectly well, 
with no dragging of the leg and no impairment of muscular 

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i 

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i 



sense. His memory was deficient to the extent that he 
remembered nothing of the first two days of his illness. 

A week later he was brought back to the insane department 
in a state of mania. His friends said he had been drinking 
heavily all the time, and had developed delirium tremens the 
previous night. 

He had the usual features of alcoholic insanity, with maniacal 
symptoms—a dangerous aggressiveness, with sudden and brutal 
violence. 

He had also optimistic delusions, which were, however, only 
of a transient nature. 

He soon calmed down ; large doses of paraldehyde (in my 
opinion the best sedative and hypnotic for alcoholics) had a 
good effect, and the acute symptoms rapidly passed away. He 
had no signs of hemiplegia, both sides being equally powerful. 

He remained here two weeks, then was induced to sign the 
pledge, and for nearly a year has remained well and steadily at 
work. 

Remarks .—The interesting features of this case are those 
which assist in elucidating the pathology of epilepsy. This 
man had the most violent fits, in fact on some occasions 
verging on the “ status epilepticus.” Following these attacks 
he had complete motor paralysis of one side, which came on 
immediately after the fits, and passed off as suddenly some 
three or four hours after. Many and varied have been the 
theories of epilepsy advanced, but I think the most reasonable 
theory of idiopathic epilepsy is that it is always cortical in 
nature, from the fact that tonic spasm followed by clonic spasm 
can be produced experimentally only by stimulating the cortex 
cerebri. 

The character of the movements is also that obtained by 
electrical stimulation of the motor cortex. 


The cells of the cortex may be regarded as pent-up reservoirs 
of energy, and in a healthy person the cells are able to keep 
their energy under control, but this control is broken down by 
a blow on the head or by the incitation of a depressed fracture. 
The next most interesting point is the paralysis following the 
fits. This I explain by the fact that the sudden discharge of 
nervous energy from the cortex, causing convulsions, produced 
a temporary exhaustion of the cells, and consequently motor 


paralysis. So soon as this exhaustion was overcome and the 

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CLINICAL NOTES AND CASES. 


109 


cells were again charged with energy, the paralysis passed off. 
The diagnosis made at the time, viz. that of concussion of the 
brain with some cortical laceration, seems to me to correspond 
best with the symptoms, and I am glad that I did not operate, 
as the patient has made a complete recovery without such 
grave interference. 


Pathological Notes on Cases of Heart Disease at the 
Durham County Asylum . By T. Aldous Clinch, M.D., 
Pathologist. 

A. Five Cases of Mitral Disease .—(1) Stenosis and incompe¬ 
tency ; death due to sudden complete obstruction of the mitral 
orifice. (2) Stenosis; no tubercle of lung. (3) Stenosis ; atrophy 
of heart; advanced tubercle of lung. (4) Stenosis ; right-sided 
dilatation ; tubercle of lung. (5) Stenosis (? also insufficiency) ; 
calcification of musculi papillares ; early tubercle of lungs. 

B. Three Cases of Cardiac Degeneration . — (1) a. No. 5. 
(2) Rigidity and calcification of the fibrous ring surrounding the 
mitral orifice; tubercle of lungs. (3) Rigidity and calcification 
(? ossification) of the same structure ; muscular degeneration. 

C. One Case of Congenital Deformity .—(1) Two cusps to the 
pulmonary valve. 

A. Five Cases of Mitral Disease . 

1. M. M—, admitted 19th May, 1894, aet. 60, female. Soon 
after admission evidence of cardiac disease was found ; at first 
mitral insufficiency, but later loud murmurs, both systolic and 
diastolic, developed. The case clinically showed no special 
features, and appeared to be doing satisfactorily under suitable 
treatment. One night, however, she rose from bed, and before 
the nurse was able to reach her dropped down insensible. 
When medical assistance arrived she was found to be dead. 

The necropsy showed slight brain degeneration; a little 
blood in pericardium ; a fatty epicardium and diseased coronary 
arteries ; dilatation of the right side of the heart; hypertrophy 
of the left side ; stenosis of mitral valve ; retroversion of the 
anterior flap , to which was adherent a mass of vegetation , and this 
was drawn back into the auricle and now laid across the stenosed 
orifice in such a manner as to completely block it; lungs slightly 

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no CLINICAL NOTES AND CASES. [Jan., 

cedematous and passively congested ; liver passively congested ; 
spleen large and swollen ; kidneys with commencing interstitial 
nephritis . 

2. G. H—, admitted 17th July, 1894, aet. 64, male. Pulse 
was then rapid (104), feeble, heart dilated, cardiac sounds 
feeble ; no murmur audible. General condition was very weak, 
and till his death the greater part of his time was spent in bed. 
Rather more than four years after his admission he was seized 
with an acute attack of cardiac dyspnoea, and when seen 
medically showed all the signs of extreme heart failure ; in 
spite of appropriate treatment he sank rapidly and died in about 
two hours from onset of attack. 

Necropsy showed chronic disease of brain ; tortuosity and 
varicosity of choroid veins ; considerable arterial degeneration ; 
normal costal cartilages; much thickened and somewhat adherent 
pericardium; fatty epicardium; diseased coronary arteries; mitral 
stenosis; thickened but competent aortic valves; cedematous 
lungs ; congested liver; spleen small ; kidneys with early cir¬ 
rhosis . 

3. Admitted January 28th, 1897, aet. 48, male. No specific 
cardiac disease was noted clinically, but the heart’s action is 
reported to have been very feeble and the circulation defective. 
Phthisis commenced soon after admission, and the patient died 
about a year later. 

Necropsy showed chronic disease of brain ; calcification of 
costal cartilages; normal pericardium ; small and atrophied 
heart (6£ ounces) ; great stenosis of mitral valve ; other valves 
normal; huge cavities in apices of both lungs ; numerous small 
cysts in liver, containing bile-stained mucoid material; large 
and soft spleen ; degenerated kidneys; tubercular ulceration of 
intestine and of skin. 

4. S. F—, chronic dement, aet. 74, female. In April phthisis 
was observed, followed in May by cardiac dilatation ; her health 
rapidly gave way, and in the middle of June there was 
commencing oedema generally, oedema of lungs and hydro¬ 
thorax. She gradually sank and died at the end of the 
month. 

The necropsy showed chronic brain disease ; costal cartilages 
normal; a little fluid in pericardium ; right-sided dilatation of 
heart; tricuspid incompetence ; thickening and stenosis of mitral 
valve , which only admits the little finger ; aortic valves normal ; 

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muscular substance of good appearance and consistence ; hydro¬ 
thorax on both sides. Left lung : emphysema, tubercle (recent), 
congestion, oedema, and collapse. Right lung : old fibroid 
phthisis ; large area of recent tubercle. Liver slightly cirrhotic ; 
gall-bladder contains thin bile and several calculi of various 
sizes ; spleen large and soft; kidneys small\ granular, contracted. 

5. M. C—, admitted 22nd November, 1895, aet. 82, female. 

She was very feeble ; severely affected with rheumatoid 
arthritis ; very feeble cardiac action ; cardiac dilatation ; no 
murmurs; pulse 78 ; emphysema and chronic bronchitis. 
Patient vegetated for two years more, gradually dying from 
asthenia. 

The necropsy showed petechiae on limbs ; dorsal kyphosis ; 
sclerosis of uncinate gyri ; basal vessels much atherosed ; 
chronic brain disease (including cerebellum) ; costal cartilages 
normal; pericardium normal; heart atrophied but covered with 
much fat; tricuspid valve thickened ; pulmonary valve normal ; 
mitral valve stenosed, c.d. 2 cm., musculi papillares calcified at 
tips ; chordae tendineae thick and rigid ; aortic valves thickened, 
rigid, and slightly incompetent; aorta and roots of large 
vessels show calcareous atheroma ; early tubercle of upper lobe 
of right lung ; remainder of lung is oedematous and congested ; 
biliary calculi ; venous congestion of liver ; small, cystic, granular 
contracted kidneys . 

It is generally taught that mitral stenosis is a disease 
especially affecting young women, but in this series of cases if 
we take those which have tolerably pure stenosis vve find that 
two cases are male and one female, and all of them past middle 
life ; by including the cases in which insufficiency of the valve 
was also present we alter the proportion of sexes but not the 
age, having now three cases in females and two in males ; all 
these patients, excepting one and that a male, have passed the 
climacteric. It may be argued, and we think fairly, that in an 
asylum an undue proportion of patients are comprised of people 
who have broken down at the commencement of old age, and 
hence our proportion of old patients is excessive. There is un¬ 
doubtedly truth in this, but if these cases really commenced in 
early life then the mitral stenosis of that period must be a much 
less rapidly fatal disease than is usually supposed, for our 
patients do not belong to a class living under conditions 
favourable to the treatment of cardiac affections. Dr. 

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I I 2 CLINICAL NOTES AND CASES. [Jan., 

Sansom (*) quotes various authorities showing that forty is 
above the average age for these patients to live. 

But there are other points which lead us to conclude that 
these cases belong to a different type of the disease. It will be 
observed that all these cases were subject to interstitial nephritis 
varying in degree. This observation was not made till the cases 
had been collected together and classified, and it is therefore all 
the more impressive. Dr. Sansom, ( l ) following Goodhart (i 880) 
and Pitt (1887), refers at length to a class the existence of 
which as a morbid entity appears to be doubted, although it 
includes the cases now described. In these cases we find through¬ 
out the body more or less evidence of arterio-fibrosis. The heart 
lesion is merely a local manifestation of the general disease. 

Tuberculosis has been shown to occur very frequently in 
mitral stenosis, and some have gone so far as to attribute the 
cardiac disease to the tuberculosis ; but though the tubercle 
bacillus has been found in cases with vegetation, and tuber¬ 
culous endocarditis has been experimentally produced, ( 2 ) the 
bacillus has never been found without them. In our cases tuber¬ 
culosis was present in three out of five cases, and was generally 
of so recent a character that it could hardly have been the cause 
of the endocarditis. That the interference with the pulmonary 
circulation, producing venous stasis and waterlogging of the 
tissues, will predispose to the attack of the bacillus is certain, 
and we therefore believe that the relation between the two is 
that the lung disease is secondary to that of the heart. 


B. Three Cases of Cardiac Degeneration . 

1. The same case as is reported fifth in Series A. 

2. M. H—, admitted 8th May, 1897, aet. 64, female. 

On admission there was no evidence of cardiac disease ; about 
nine months later he fell and fractured his thigh ; lobar pneu¬ 
monia set in, and patient died. 

The necropsy showed ununited fracture of thigh; basal 
vessels of brain much diseased ; chronic brain disease ; costal 
cartilages not ossified ; pericardium toughened ; epicardium 
fatty; right side of heart dilated; left side hypertrophied; 
rigidity and calcareous degeneration of fibrous ring surrounding 
mitral orifice ; bases of aortic cusps calcareous , valve competent; 

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I 13 

pneumonia of lower lobe of left lung, probably infected with 
tubercle in patches ; old cured phthisis in right apex. Liver 
cirrhotic, kidneys normal to naked eye. 

3. Of this case we have the necropsy notes only. A. L—, 
aet. 80, female. 

Brain shows chronic disease; chronic vascular disease 
in ganglia ; much atheroma of all large vessels. Chest con¬ 
tracted and approaching the type seen in osteomalacia ; costal 
cartilages slightly calcareous ; pericardium normal, sac full of 
slightly turbid fluid ; epicardium exceedingly fatty. Coronary 
arteries tortuous and atheromatous. Myocardium very soft and 
dark in colour. Tricuspid valve slightly fibrotic ; pulmonary 
valve normal; mitral valves somewhat thickened and rigid ; the 
fibrous band surrounding the mitral orifice is thickened to the size 
of a cedar pencil ', and is of the consistence and appearance of can¬ 
cellous bone . The lungs show senile atrophy. Liver is fatty. 
Kidneys are very congested and slightly atrophied. 

Of these cases only the last two need special comment; it 
would appear that the degeneration described is exceedingly 
rare ; it is not mentioned in Zeigler’s Pathology or in Clifford 
Allbutt’s System of Medicine . One might assume that it 
would lead to increased accentuation of the first sound in the 
aortic area, and in cases of mitral incompetence associated with 
it would conduct the murmur to the aortic area in rather a puz¬ 
zling and misleading manner. 


C. One Case of Congenital Deformity . 


1. Two cusps to the pulmonary valve. 

Patient was an epileptic ; he showed no symptoms during 
life. 

It would appear from researches of Dr. Simpson ( 8 ) that 
while two cusps to the aortic valve and four cusps to the pul¬ 
monary are comparatively common, two cusps to the pulmonary 
is much rarer, especially so perfect a specimen as the present 
one. In this case there is a slight indication of a division in 
the anterior one. 

I must express my thanks to Drs. Skeen, Geddes, and Jones 
for permission to make use of their clinical notes. 


(*) A. E. Sansom, Clifford Allbutt’s ‘ System of Medicine.’—( a ) Michaelis und 
Blume, ‘ Deuts. medicin. Wochen.,’ September 1st, 1898.—(*) Simpson, ‘Journal 
of Anatomy and Physiology,’ July, 1898. 

XLV. ^.OOQie 



OCCASIONAL NOTES. 


[Jan., 


114 


Occasional Notes. 


The Lord Chancellor s Lunacy Bill . 

The Lord Chancellor’s Lunacy Bill has now been introduced 
into Parliament in two successive sessions, and on each occasion 
has duly perished with the innocents. The time must there¬ 
fore, if we may rely on previous analogies, be drawing near 
when the measure may be expected to take its place on the 
statute book. Under these circumstances a brief critical 
summary of its main provisions may not be inopportune. The 
first point of importance is the curtailment of the duration of 
an urgency order from seven days to four, coupled with the 
requisition of what is practically a new “ statement of parti¬ 
culars,” to be signed by the person signing the urgency order, 
and by the medical practitioner granting the accompanying 
certificate. We know the kind of case at which this provision 
is aimed. It is doubtful, however, whether such cases are 
sufficiently common to justify an enactment which will make 
the already difficult task of securing the curative treatment of 
insanity in its early stages more difficult still, by at once 
rendering the urgency order procedure cumbrous, and increasing 
the reluctance of medical men to certify. Other provisions in 
the Bill have a contrary effect. Such are those enabling a 
justice virtute officii to be appointed a special justice under 
Section 10 of the Act of 1890, prohibiting fees in respect of 
proceedings for a reception order before a judicial authority, 
and authorising the detention of a lunatic in a workhouse for 
not more than three days, even if the inquiries under Section 27 
of the Act of 1890 cannot be completed before the order is 
made. It may be added that to the persons disqualified for 
signing certificates under Section 32 (1890) the Bill annexes 
two new ones, viz. the person making the reception order and 
employes of managing committees or licensees. Direct pro¬ 
vision is made for pensions to officers and servants of asylums, 
and for the allowance of gratuities in cases of injury specifically 
attributable to the nature of the duty of the injured person 

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incurred by him without his own default in the actual dis¬ 
charge of that duty. Lastly follow a variety of strictly legal 
and judicial provisions. Section 322 of the Act of 1890, 
dealing with offences against patients, is to include “ striking,” 
and to extend to workhouses, impliedly excluded hitherto by 
the definition of “ institution for lunatics” in Section 341. The 
Master in Lunacy, subject to the rules, and to the annulment or 
variation of his orders on appeal, is to have the jurisdiction of 
the Judge in Lunacy—a provision which practically will make the 
Lords Justices appellate judges only. 

“ Arrest of mental development ” is added to the grounds of 
jurisdiction under Section 116. It was doubtful whether this 
common condition came within the words “ infirmity of mind 
arising from disease ” in that section. By Section 116 patients 
are brought within the range of duty of the Chancery Visitors. 
And the effect of inquisitions upon reception orders is at last 
defined. Briefly the result is this. If the alleged lunatic is 
found sane the reception order determines forthwith. There 
is room here for greater precision, and for directions as to notice 
to the person having the lawful control of the lunatic. If the 
finding is one of incapacity to manage himself and his affairs, 
the reception order continues in force till a committee of the 
lunatic person has been appointed. If the finding is incapacity 
to manage affairs only, the order determines, but the judge may 
give directions as to residence, care, treatment, &c., so long as 
a reception order stands, but no longer. The duty of the 
Commissioners in Lunacy to visit the patient subsists. What 
the effect of proceedings under Section 116 on reception orders 
is to be is a point that might with advantage be cleared up. 


Criminal Evidence Act . 


The Criminal Evidence Act, 1898, has now come fairly into 
operation, and it is already possible to forecast its working in 
certain directions. In the first place the Act will certainly 
facilitate the proceedings of our police courts by enabling the 
magistrates to dispose of cases in which, but for the evidence of 
the prisoner, they would have had to order a remand for in¬ 
quiries. Again—and this is rather a serious matter—it looks as 


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116 

if the fear that silence would be interpreted prejudicially to 
them by the jury will exercise a practical compulsion on 
prisoners to give evidence in a vast majority of cases. This 
consideration makes it all the more important that no undue 
advantage should be taken of prisoners in cross-examination, or 
in the summing up of prosecuting counsel. So far there has 
been nothing to complain of in either respect. Lastly, there 
can be no question that the Act will secure the conviction of 
many prisoners when they might not have been found guilty 
but for their own evidence. The recent case of Dr. Whitmarsh 
is an illustration of this fact; the case against him, though strong, 
rested largely in itself on evidence which was circumstantial and 
not direct, and had matters been left there the second jury 
which tried him might have disagreed as the first did. But the 
prisoner clinched the case for the prosecution by denying inci¬ 
dental statements of fact of which there was abundant proof, 
and above all by fixing the date when Alice Bayley last called 
upon him. Whether this quality in the new Act with which 
we are dealing is a merit or a defect is a point on which opinions 
may differ ; but it shows the need for a very cautious adminis¬ 
tration of the measure if the conviction of the innocent is to be 
avoided. 

Various other issues have been raised under the new Act. 
We may pass by the question, no longer of any practical 
interest, as to the date when it came into operation. But the 
Court for Crown Cases Reserved has already decided (Queen v. 
Rhodes) with unimpeachable propriety that a prisoner has no 
right to be called before the grand jury, and that the statute 
does not interfere with a summing up by prosecuting counsel 
under Denman’s Act. In the same case it was held that the 
fact that a prisoner declines to give evidence may, at his dis¬ 
cretion, be made the subject of comment by the presiding judge. 
It is difficult to say that this ruling is not legally sound. But 
it practically will make prisoners compellable as well as com¬ 
petent witnesses. A serious division of opinion has been 
produced by the question whether a prisoner can be prosecuted 
for perjury in evidence which he gives in his own behalf. Mr. 
Justice Wills, on circuit, took the negative view. Mr. Justice 
Ridley has adopted the affirmative, and has actually ordered a 
prosecution, besides commenting on the evidence of prisoners 
in terms which have been severely criticised by the legal pro- 

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II 7 


fession. The solution of this difficulty will be awaited with 
great interest. 


The Case of Dr. J, A, Campbell. 

Our action might be misjudged if we were to leave unnoticed 
the trial (reported in our medico-legal column) of Dr. J. A. 
Campbell, of the Garlands Asylum, Carlisle, for an offence under 
Section 324 ofcthe Lunacy Act, 1890-91. We need not say 
that we refer to the event with the deepest pain. 

The law has rightly provided special penalties for such an 
offence, an offence against the most helpless of creatures—a 
human being deprived of the great human attribute of reason, 
and left defenceless to the power of others or to the prompt¬ 
ings of brute passion ; an offence, too, against all principles of 
fiduciary honour; an offence, in fine, so revolting that it almost 
falls under the category of unnatural crime. The common 
sense of mankind calls loudly for the exemplary punishment of 
such offences ; and our specialty, which has always been the 
great protector of the insane, strongly upholds enactments framed 
by the law in accordance with the spirit of natural justice. 

The case before us has other points of interest for us besides 
the directly humanitarian. It interests us further, inasmuch as 
insanity was pled in exculpation of the prisoner. This plea 
did not surprise anyone who had either known Dr. Campbell 
recently, or had heard in detail the circumstances of the act 
charged against him. 

The trial proceeded on the familiar lines. The prosecution 
adopted the view that mere alcoholic intoxication at the 
moment when the crime was committed accounted for the 
prisoner’s conduct. The judge, having pointed out that mere 
drunkenness at the moment was no defence, proceeded to lay 
down in a quite unmodified way the law as pronounced in the 
McNaghten case. It was put to the jury: was the accused 
through insanity incapable of knowing what he was doing ? or if 
he did know what he was doing, was he incapable through 
insanity of knowing the nature and quality of the act ? It is 
doubtful what effect this had upon the jury. It must have been 
perfectly evident, even without entering upon Sir James Stephen’s 
subtleties, which Mr. Justice Phillimore very cavalierly swept 

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aside, that the accused did not know the nature and quality of 
the act which he was committing ; so that the real question 
remained—to what was this ignorance due ? Indeed, the intro¬ 
duction of these considerations was probably favourable to the 
accused by drawing the minds of the jury from the direct issue, 
“was he insane or not?” 


The evidence of insanity, the exciting cause of which being 
in all probability recent alcoholic excesses, was enormously 
strong, so strong as to be irresistible ; for there was in addition, 
no doubt as a predisposing cause, a period of thirty-one years 
in asylum service operating on a certain morbid quality of brain. 
Medical men and laymen, some of whom had known him for 
years, and some of whom were strangers to him, deposed to 
having met the prisoner shortly before the date of the offence, 
and to having formed and expressed at that time the distinct 
opinion that he was insane. By a curious chance two doctors 
in general practice in Carlisle, unbiassed and thoroughly respect¬ 
able witnesses, had seen the prisoner on the day on which the 
offence was committed little more than an hour before its 
commission, and were then satisfied that he was not drunk, and 
that he was insane. Either of them would have been prepared 
to certify; and one, so forcibly was he struck by Dr. Campbell's 
condition, said that if the latter had been a pauper patient he 
would have communicated with the parish doctor as to Dr. 
Campbell's state (that is, with a view to restraint). 

It is true that two medical men were called by the asylum 
committee to show that the prisoner was not insane, and that 
mere drinking accounted for his condition ; but this evidence, 
besides being in conflict with an enormous body of expert and 
non-expert opinion, was discounted by the fact that these wit¬ 
nesses for the prosecution had been in the habit of daily seeing 
the accused, and had evidently failed to appreciate his degene¬ 
rated condition. Besides, the prosecution endeavoured to prove 
too much, and brought up some contradictory evidence to the 
effect that the prisoner was not a man of drinking habits. 

No one who followed the details of the trial can feel a 
doubt as to the verdict, or can fail to see that Justice has done 
fairly when, weighing in one scale what a lunatic had suffered 
and in the other what a lunatic had done, she struck the^balance 
by condemning the latter to confinement during Her Majesty's 


pleasure. 


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Sad end to a life much of which was spent in excellent 
service to the insane! pitiable termination to a career not with¬ 
out distinction ! 

It is unnecessary for us to point one obvious moral which 
suggests itself from this shocking case. So dreadful are the 
results we daily see from the drinking habits of our population 
that one appalling case more will hardly count. “ They have 
Moses and the prophets; if they will not hear them, neither 
will they be persuaded, though one rose from the dead.” 

But there is another point to which we feel constrained to 
refer. Mr. Justice Phillimore in his charge said that “ he must 
draw the attention of the jury to the strange condition of things in 
the asylum. 

Some witnesses, superintendents of other asylums, had given 
evidence that Dr. Campbell showed signs of insanity months 
and even years ago, and yet he was allowed to go on in his 
position superintending the asylum. The situation became 
almost grotesque when they found that Dr. Campbell at the 
time gave evidence at the Assizes in a case where a man was 
charged with murder.” 

It most impressed the judge that the prisoner should have 
been lately in the position to give evidence in the case of another 
lunatic. To us who are interested also in those of the insane 
who do not come into court, it seems doubly sad and wrong 
that, whether the pleading of the prosecution (the asylum com¬ 
mittee) or of the defence (the asylum superintendent) may 
have been correct, the state of things revealed in this trial 
should ever have been allowed to come about. 


Luccheni: the Murderer of the Empress of Austria. 

It is one of the most difficult problems of jurisprudence to 
devise some method of repression for crimes of the class that is 
called “ political.” These crimes are rarely the direct result of 
need, and are seldom committed by members of that order of 
beings who live parasitically upon society and constitute what 
is known to the police as the criminal class. 

The “political” murderer, the assassin of emperors and 
presidents, the dynamitard, the Invincible jyho makes history 

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by letting out his fellow-subject’s bowels with an amputating 
knife, has commonly but one human motive which can be 
appealed to, namely, vanity. The horror of the world, the 
public trial, the vast commotion in the press, the abuse and 
execration heaped upon the prisoner who is safe behind the 
bars, are a sincere delight to him. Nay, in countries where 
executions are still public, there can be no doubt that a last 
appearance on the scaffold and a last display of bravado which 
will be telegraphed all over the globe have a positive charm for 
minds of this type. 

Hence it is perhaps salutary when these wretches can be 
made to feel that they are merely the morbid products of a 
particular age, no more heroic than the beggars who at another 
period of the history of civilisation crouched at Dives’ gate. 

The disgusting Luccheni, whose murder at Geneva of the 
kindly if eccentric lady who shared the uneasy honours of the 
Hapsburg crown threw all Europe into mourning, was a speci¬ 
men of this class, and has formed the subject of a special study 
by Professor Lombroso from the criminal anthropologist’s point of 
view.(i) Lombroso’s studies of the criminal generally and of 
the anarchist in particular are too well known to our readers to 
need description, and in the present case he follows his usual 
methods. Luccheni, he tells us, is the illegitimate son of a 
domestic servant by her master, who is a drunkard. Both 
parents, who are still alive, were originally from Parma. The 
mother is now in America. Luccheni was born in Paris, where 
his mother put him into a foundling hospital, whence he was 
sent back to his parental country, and placed in a similar in¬ 
stitution in Parma ; mere hotbeds and nurseries of crime, all of 
them, seems to be Lombroso’s verdict on these places. From 
here he was boarded with two families : of the first, the father 
was given to drink ; the mother led a very immoral life. The 
second family seem to have made a livelihood chiefly by begging. 
Later on he was sent to school, and from thence he became a 
servant for a couple of years. Then he served his term as a 
soldier, having in the meanwhile spent a short time in Switzer¬ 
land, where he probably became an anarchist. 

Returning to Switzerland after his service as a soldier, he 
became suspected by his associate anarchists, and determined to 
commit a crime against a sovereign, so as to show his devotion 
to the cause. 


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At about thirteen years old Luccheni had an epileptic attack. 

Lombroso describes him as having drooping lids, very pro¬ 
minent superciliary ridges, strongly marked zygomata, and heavy 
lower jaws. Forehead low and receding, facial angle small, 
and the subject is brachycephalic. Examination of his hand¬ 
writing shows an alternation of macrography with micrography, 
and to this much importance is attributed, not only because this 
state is often present in epileptics, but because it is associated 
with impulse and with double personality. The latter condition 
is held to have existed because Luccheni was fond of children, 
and was a good servant ; he also on one occasion expressed an 
enthusiasm for military service, and yet was an anarchist, and 
afterwards an assassin. This double personality is characteristic 
of the hysterical and epileptic. It would seem to us that in¬ 
consistency of character is common enough among all members 
of the human race. Luccheni’s conduct at his trial, and indeed 
throughout—his utter heartlessness, his blatant and blackguardly 
boasting, his unmeaning jokes with his lawyer, his efforts to 
attract the attention of the press,—are all of a piece with his 
entire character, and in no way fit with that alternation of piety 
and violence, of high principle and rowdy behaviour, with which 
we are all so familiar in the unhappy epileptic. Epilepsy 
explains much according to Lombroso, but not all. If the 
individual organic cause counts for much, the circumstances of 
his birth and the environment in which he lived count also for 
a very great deal. To this we may all subscribe, without being 
quite able to follow the social and political ideas which Professor 
Lombroso very bravely, honestly, and earnestly urges upon his 
countrymen. Something has unhappily made Italy specially 
fertile in these wretches, but to attribute this in chief part or 
even largely to the financial condition of the country, and to 
the consequent distress of the people, seems to us to be merely 
to seize the nearest and most convenient explanation. Distress 
no doubt is not so widely spread in England as in Italy, and 
yet we have plenty of it, quite enough to raise a good crop of 
anarchy if distress were alone necessary for that. 

It is true that Lombroso, with that odd want of perspective 
in his views of things insular which is so often to be noted 
among the greatest Continentals, gives us to understand (2) that 
the English are saved from anarchism by the diverse fanatical 
sects that exist in this island, and the various benevolent and 

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other societies. All these things occupy people’s minds and 
give vent to their energies. “In England Caserio would per¬ 
haps have found a place in the ranks of the Salvation Army, 
which would have furnished food for his fanaticism, and for his 
need of action.” 

But these arguments appear to us mutually destructive: for 
on the one hand we venture to doubt the power of the Salvation 
Army to suppress a bread riot should such a thing again 
unhappily break out in England ; and on the other it would 
appear that the classes who furnish the anarchists are by no 
means the most needy, or those who suffer most from distress. 

Both as a pioneer in science and as a reformer in social 
affairs Lombroso appears to have encountered difficulties which 
it may console him to know are not peculiar to Latin races. 
His article in Le Revue des Revues concludes thus :—“ As for the 
imbecile notion of some Latin nations, who, instead of dis¬ 
infecting the surroundings, think it better to suppress the 
physicians when they suggest remedies, and the writers when 
they labour for the improvement of social conditions, it could 
not spring up except among classes and peoples unworthy to 
live in our century” 

(!) “ Luccheni giudicato dal punto di vista antropologico-psichiatricsee also 
41 Le Crime de Luccheni,” by the same author, in Revue des Revues, No. 21, 1898. 
—(*) See Gli Anarchisti. 


The Bedborough Case . 

We regret that Mr. Havelock Ellis’s work on Sexual Inver¬ 
sion should have been among the books which Mr. George 
Bedborough pleaded guilty to having sold, when he was 
charged with the sale of obscene literature at the Old Bailey 
on October 31st. Mr. Ellis’s well-known reputation as a 
criminal anthropologist will be a sufficient guarantee of his 
motives in writing the work in question, but it is certainly 
most unfortunate that a man who must plead guilty of the 
sale of an indecent lecture and an indecent journal should have 
the opportunity of claiming a scientific study as part of his 
peccant matter. 

In dealing with the German original of this work, and with 
the kindred work of Raffalovich in this Journal a year and a 

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123 


half ago, we pointed out the danger of such works getting into 
improper hands, and being used for other purposes than those 
of scientific research (see vol. xliii, p. 570). It is now evident 
enough that our fear is justified, and we trust that observers in 
the field of sexual depravity will bear in mind the lessons of the 
Bedborough case. The perpetual repetition of the theory of 
Ulrich, that some people are naturally possessed of a per¬ 
verse sexual feeling, is tiresome. We are never favoured with 
an atom of proof, and writers seem to imagine that they 
advance their arguments by heaping up unsavoury details— 
details which, however harmless they may seem to us who are 
accustomed to the vagaries of insane passion, will, if they fall 
into the hands of the vulgar, be treated as a mere bundle of very 
dirty stories, and as such are liable to become part of the stock- 
in-trade of the pornographic bookseller and his wretched clientele . 
We are sorry for Mr. Ellis, especially as he was unable to defend 
himself, the charge being only against the vendor of various 
works ; but we are of opinion that he should have exercised 
more care with regard to the mode of production and sale of 
his volume in its English form. If it is found impossible to 
avoid the introduction of monographs on such subjects into the 
secret drawer of the dealer in indecent books, then in our opinion 
the production of these monographs should cease, as they are 
likely to do more harm to their readers among the general public, 
and to their authors, than will be compensated by the instruc¬ 
tion they give to those who read them with merely scientific 
desire for information, or who have already had more than 
enough of detailed cases. 


Pathological Laboratories. 

The last Report of the Pathologist to the London County 
Asylums gives evidence of the high quality of the work in 
progress at the Asylums Laboratory. Without attempting a 
review of the Report, we may here allude to the chief topics 
with which it is concerned, and these are—The occurrence of 
acute fatty degeneration in certain muscles in general paralysis 
of the insane ; the action of cholin—a product of degenera¬ 
tion of brain tissue, which exists in the cerebro-spinal fluid of 

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124 OCCASIONAL NOTES. [Jan., 

general paralytics, and of other cases of chronic brain disease 
—in producing a fall in the blood-pressure, with suggestions as 
to the dependence of certain of the phenomena of general 
paralysis upon this action; the relationship of syphilis to 
organic brain disease and general paralysis ; the pathology of 
the primary degeneration of the neuron in certain affections of 
the cord ; the minute changes in the cortex of general para¬ 
lytics, and studies of the vagus and sympathetic nerves in 
general paralysis ; the estimation of phosphorus and sulphur in 
brain and spinal cord in healthy and diseased conditions, with 
an associated histological study of the cortex cerebri in the 
same cases. Dr. Mott also promises the publication of the first 
instalment of the ‘ Archives ’ of the Laboratory, with a full 
account of the work which has been accomplished. That the 
disease—general paralysis—should occupy such an important 
place in the Report is natural enough, for the brain in paralytic 
dementia presents to the pathologist tangible realities which, we 
would assert, are more than the sum-total of the conditions pre¬ 
sented by that organ in the other forms of insanity. Tuczek’s 
observation of the degeneration and atrophy of the tangential 
system of fibres in the cortex of general paralysis has been con¬ 
firmed by various observers, and now by Dr. Mott. We do not 
remember to have seen any adequate suggestion in reference to 
the pathological significance of this degeneration ; and, as far 
as we are aware, there is not any evidence to show that the 
tangential fibres are affected separately from other medullated 
fibres of the cortex in diseases of the cortex, though we believe 
that some are of opinion that in certain morbid conditions they 
suffer the earliest amongst such fibres. We consider that, in 
regard to the medullated fibres of the cortex generally, there is 
considerable scope for prosecuting the work of Kaes in this 
field in the case of insane brains. 

Dr. Mott, we observe, expresses the opinion that the changes 
in the nerve-cells of the cortex in general paralysis are partly 
due to primary progressive decay of the cells, partly to 
changes brought about by stasis in the vessels. The latter, we 
presume, are changes due to anaemia. We gather that Dr. 
Mott is of opinion that the formative proliferation of the glia- 
cells (sclerosis) is secondary to the necrobiotic changes in the 
neuron. We believe that this view, in contra-distinction to that 
which regards the vascular and connective-tissue changes as the 

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earlier, is the more widely held now. The views of Bevan 
Lewis upon the “ scavenger ” function of the hypertrophied 
glia-cell have not, we think, received support from other writers. 
Doubtless the point is most difficult of proof. We shall await 
with interest the latest views of Bevan Lewis in the second 
edition of his work, which we understand is about to appear. 

Dr. Mott has devoted much pains to tracing the relationship 
between syphilis and organic brain disease, and more particularly 
general paralysis, and he is in accord with the increasing 
number of authorities who believe that syphilis is the most 
important factor in the production of general paralysis. To this 
view we note that Oppenheim subscribes in the second edition 
of his Handbook of Diseases of the Nervous System , published 
in May last. 

The interesting report, to some features of which we have 
alluded, is available for the perusal of our readers, and we need 
make no further reference to it. 

In this connection we would refer to “ Memorandum No. 3,” 
just issued from the Laboratory of the Scottish Asylums, which 
sufficiently indicates the good work in progress there. Inter alia , 
the “ Memorandum ” draws attention to the list of asylum 
demonstration-sets now available at the laboratory—prepara¬ 
tions and slides for the purpose of study. This would appear 
to be one of those things which they do better in Scotland. It 
may be that at the Laboratory of the London County Asylums 
such demonstration-sets are in course of preparation, and that 
the medical officers of the metropolitan asylums enjoy the same 
privileges as their Scottish colleagues. As regards English 
county asylums generally, even when there is a pathological 
laboratory we fear that much time is lost, and that many mis¬ 
takes are apt to be made, by men who have to start pathological 
work without experience, often without guidance, and without 
the corrective influence of a standard demonstration-set of 
sections. 


The Innervation of Intra-cranial Blood-vessels . 

That the nerve-fibres follow the course of blood-vessels in 
the membranes enveloping the brain has long been known, but 
upon the subject of the innervation of the cerebral blood-vessels 

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126 OCCASIONAL NOTES. [Jan., 

there has hitherto been no certain information. Whilst some 
writers assume that these vessels are innervated, others assume 
the contrary. What is more to the point, able investigators 
have stated that in the vascular plexuses of the brain no nerves 
are to be found ; and that whilst nerves can be traced to minute 
arteries in the brain, they cannot be followed to their termina¬ 
tion. To this statement Kolliker gave the weight of his 
authority in his Gewebelehre , and we believe it has been 
generally accepted. Recent writers have stated that the muscu¬ 
lature of the blood-vessels, not being under nerve influence, has 
only the value of an elastic membrane. There would seem to 
be much inherent improbability in such a view, but evidence 
adequate to controvert it has been lacking. It is therefore 
satisfactory that later research gives considerable ground for 
replying to the question as to the innervation of the intra¬ 
cranial blood-vessels in the affirmative. In 1897, Obersteiner 
figured a preparation in which nerves were shown on the smaller 
arteries of the pia by means of chloride of gold. This 
rendered it probable that other intra-cranial vessels possessed 
their own nerves. In a paper just published Dr. A. Morison 
states that he has succeeded in staining the nerves “ coursing 
with the vessels of the pia mater ” in the foetus of the cat. The 
preparations were treated by Sibler’s haematoxylin method. 
Dr. Morison describes the nerves as “ twisting in some instances 
round the vessels, and terminating in a plexiform manner on 
them, the mode of termination being most visible on the larger 
vessels.” The nerves are interrupted at intervals by a nuclear 
body. The author describes and figures ganglion cells also, in 
the nerve-trunks. Further research will doubtless be made in 
tjiis direction, and embrace in its scope the minute vessels 
within the brain substance and those of the vascular plexuses 
It is to be hoped that definite warrant may be obtained for the 
conclusion that the intra-cranial vessels have the ability actively 
to contract and dilate, and that light may thus be thrown upon 
a question of great pathological importance. 


Phthisis in Asylums and the Segregation of Phthisical Cases . 

When an asylum has, as compared with asylums in general, 
a high mortality from phthisis, the reports of official inspectors, 

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127 


which of necessity are largely comparative, are apt to strike a 
warning note, with allusions to over-crowding and insanitation. 
That these evils exist, singly or combined, in most asylums not 
of very recent date is probable enough. But the physician on 
the spot, with his considerable knowledge of the district from 
which the asylum draws, may be excused if his own view is at 
variance with that of the occasional inspector, in that it ascribes 
a preponderating influence in the causation of the phthisis 
which his asylum shows to heredity and to unfavourable en¬ 
vironmental conditions obtaining at the patients* homes. We 
can conceive the case of an asylum drawing largely from a 
population engaged in dust-producing occupations, an institu¬ 
tion against which the reproach of over-crowding and insanita¬ 
tion could not be brought, but which, nevertheless, has a high 
rate of phthisis. Again, institutions drawing from the western 
parts of the kingdom, from amongst the dwellers on the 
“ Celtic Fringe,’* numbers of whom pass their lives in valleys 
and upon bleak hillsides, where mists and sleet are more 
familiar than the sun’s rays ; the scattered populations amongst 
which intermarriage and imbecility are respectively almost 
necessary and inevitable ; institutions drawing from such com¬ 
munities should, we think, be accorded a large measure of 
official indulgence in respect of criticism of the kind above 
mentioned. 

Putting aside the question of the mode of origin of phthisis 
in asylums, and turning for a moment to that of the condition 
as it exists, and its treatment, we are disposed to think that 
very little has been done as yet in the way of segregation of 
phthisical cases in these institutions. This, we are aware, is a 
well-worn theme, but yet one by no means practically disposed 
of. At the present time, when general attention is being 
directed to the risk of contagion in phthisis, and the desir¬ 
ability of destroying phthisical sputum, and of segregating the 
patients, it is opportune to revert to the question as it presents 
itself in asylums. At present cases of phthisis are commonly, 
we believe, accommodated in the hospital ward, or other 
continuous observation ward, in association with other patients ; 
and in many asylums the hospital contains, in addition to 
ordinary sick patients, cases requiring continuous observation 
on account of their mental state, but who physically are 
comparatively well. This undesirable association of phthisical 

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with other patients, some of whom are sure to be promising 
cases for recovery, is doubtless fundamentally due to reasons of 
economy. That is to say, there is often hesitation in laying 
before committees plans for the erection of a special ward for 
phthisical cases, the provision of which would entail increased 
expense, in the way of addition to the nursing staff and 
arrangements for extra sick nursing. It is to be hoped that 
the governing bodies of asylums may be brought to participate 
in the enlightenment of the public, now in progress, in respect 
to the means by which phthisis is spread, and by which the 
risk of infection is reduced. Asylum physicians will then 
make their recommendations on segregation with more con¬ 
fidence of a practical issue thereto. 


The Psychological Section at the Edinburgh Meeting . 

Adequate notice of this meeting was unfortunately crowded 
out from the October number of the Journal,— it is unnecessary 
to say from no want of interest or value, as the reports in the 
present number will testify. 

Sir John Batty Tuke’s address on the “ Modem Conception of 
the Etiology of Insanity” was conceived on the most advanced 
lines of thought, with the scientific insight and practical sug¬ 
gestiveness which we are accustomed to expect from him. 

The more thorough appreciation of the causes and of the 
pathology of insanity, certainly justifies the hope expressed by 
Sir John, that considerable improvement in the treatment of 
the insane will result at no distant date. This, as he suggests, 
will especially follow on the improved medical care in the 
earliest stages of disorder, by the wider appreciation of these 
conditions by the general body of the profession. We heartily 
join him also in condemning the delays in treatment under the 
English law, but we cannot hope that there will soon be any im¬ 
provement in this respect; progress in this direction is certainly 
not within the range of practical probabilities at present. 


Drunken Women . 


The Liquor Commission has drawn from an eminent surgeon 
the remarkable statement that female drunkenness, in his ex- 


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perience, had been traced almost without exception to physical 
and mental suffering. Generalisation from special experience 
is always apt to be misleading, and this is probably an excep¬ 
tionally striking instance of the untrustworthiness of one-sided 
views. 

Neurologists and alienists, in the class of cases coming to 
them, might similarly say that female drunkenness was in large 
measure due to neuropathic or insane heredity ; the general 
physician, especially in towns, would probably ascribe a large 
proportion to the tadium vita and want of interests or 
occupation amongst the women of the middle class ; whilst the 
prison surgeon would probably find the predominant cause in 
prostitution and irregular habits of life. 

The fact of such a sweeping generalisation can only, therefore, 
be taken as an evidence of the very strictly limited class of cases 
on which the observation was made. 

That treatment of drunken women in inebriate homes is 
“ fundamentally wrong,” as this hasty generaliser asserts, must 
certainly need the qualification “ in regard to those who require 
other, possibly surgical, treatment.” Even with this qualification 
the assertion is erroneous, for the inebriate habit when once fully 
established will often endure after the original cause has long 
ceased to exist or operate. Total deprivation is, in the ex¬ 
perience of most physicians, a fundamental necessity of cure 
when cases have reached this condition from whatever cause ; 
and the diminution of the facilities of obtaining drink, which 
this confident writer apparently does not consider important, is 
by common experience proved to be of essential value. 

Conclusions based on inadequate or one-sided experience, if 
sufficiently, strikingly, and boldly put, are very attractive to the 
public mind, and so constitute a real danger in questions which 
have ultimately to be decided by public opinion. The small 
modicum of truth renders the error still more pernicious by 
rendering the falsity more easily acceptable. 

Flimsily constructed conclusions such as these cannot be too 
forcibly reprobated, or the habit of making them too much 
discouraged ; this habit, to borrow an expression from the 
building trade, might be appropriately stigmatised as “ jerry gene¬ 
ralisation.” 


XLV. 


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The Frederick Case . 

The Christian Scientist question has been very prominently 
before the public recently in connection with the death of Mr. 
Frederick, an author and writer of some repute, on whom an 
inquest was held. 

Christian Scientism has been negatively described as being 
neither Christian nor scientific ; positively it is perhaps the 
finest example of irrationality that has ever obtained a widely 
accepted credence. The fact that it is credited to have obtained 
acceptance by 200,000 persons in America, comprising many of 
the so-called educated classes, is a source of astonishment, but 
gives also reason for thought. 

Education is such a widely misapplied term. Persons who 
have learned certain subjects—Latin and Greek, for example— 
are generally termed educated ; but it often happens that this 
degree of learning is little more than an exercise of the memory ; 
the judgment and reason having been either dwarfed or left quite 
uncultivated. The want of observation and judgment in the 
mere bookworm has long offered a subject of amusing ridicule 
to the novelist and dramatist, and the lack of these is certainly 
the basis of the acceptance of such a farrago of nonsense as 
Christian Scientism by these “ educated ” classes. 

Persecution or prosecution of the professors of this craze is 
to be deprecated, as only giving the advertisement they desire. 
Left strictly alone, these monstrous mushroom growths decay as 
speedily as they spring up ; and although sympathy must be felt 
for their victims, this is considerably soothed by the reflection 
that they are of a class who, in any event, would probably not 
have aided greatly the progress of human development. 


Over-burdened Children in Germany . 

Under the above title lately appeared in a Manchester con¬ 
temporary a very interesting account, by an English lady, of a 
holiday visit to Herr Triiper’s educational institution for back¬ 
ward and mentally defective children at Sophienhohe, near Jena. 
Here is the home of between thirty and forty boys and girls 
who are “ not as other children are,” mostly of the higher social 

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class, for the average payment (we have heard) is not far from 
£100 per annum. Herr Triiper and his wife personally super¬ 
intend the establishment, which has a staff of three trained 
male teachers, four female teachers, two nursing sisters, a gar¬ 
dener, and a joiner, besides domestic servants. The daily 
routine is as follows :—Rise at 6 a.m., first breakfast at 6.30, 
lessons (none more than forty-five minutes, with intervals for 
play), 7.1 5 to 9 ; 9 to 10, recreation and second breakfast ; 10 
to 1, lessons ; dinner, 1.15. After dinner, rest or recreation ; 
and in the afternoon lighter tasks such as singing and drilling. 
It is stated that in every case the lessons, rest, and play are 
carefully arranged with a view to the physical and mental capa¬ 
city of the child ; but we would venture to remark that such a 
time-table as that above set forth would be beyond the endur¬ 
ance of the British feeble-minded child, however well adapted 
to his German congener. We are not informed what proportion 
of time is given in the daily instruction to manual and mental 
work respectively ; but four and three quarter hours of school 
before dinner, however varied, seems to us a case of “ Nimia 
diligentia magistri” The time-tables of our own training 
institutions for mentally feeble children of a similar class to 
those received by Herr Triiper show but from two to three 
hours’ school-work in the morning, and—what we miss in the 
German plan—a distinct interval for active physical exercise, 
such as a smart walk or game of cricket, before dinner ; while 
the couple of hours in the afternoon are usually devoted to 
manual training, music, and other matters not calling for much 
mental exertion. We fear, indeed, that such a curriculum as 
Herr Triiper’s would tend to aggravate rather than relieve the 
“ over-burdened ” condition of the backward British child. 

The writer of the article is evidently not completely in¬ 
formed as to all that has been done of recent years in this 
country for the education and training of mentally feeble and 
other exceptional children. In addition to the old-established 
institutions for idiots and imbeciles, there have sprung up of 
recent years several educational homes for children incapacitated 
by mental or physical infirmity for ordinary school life, most of 
them under medical direction, but not (as stated in the article) 
44 all very expensive” as compared with Herr Triiper’s. The 
National Society for Promoting the Welfare of the Feeble¬ 
minded seeks to supplement the “ special classes ” established 

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by several of the school boards of England by supplying resi¬ 
dential accommodation and training in useful industry after 
school age in the case of children of poor parents, while there 
are some half-dozen that receive similar pupils of a higher 
social class at various rates of payment. One advantage that 
these latter have over Herr Triiper’s establishment is that 
as a rule they do not receive pupils of so wide a range of 
incapacity as he does ; and there is no doubt that the higher 
grades of feeble-minded children are better dealt with if en¬ 
tirely separated from those properly designated imbecile . Herr 
Triiper's work in carrying on a “help-school for the higher 
schools ” meets an undoubted social want ; and we are glad to 
know that the scientific as well as the practical aspects of the 
subject occupy his attention. 


Juvenile Criminals . 

The Commissioners of Prisons for England and Wales in 
their last report comment upon the very slight improvement in 
the educational status of the criminal classes since the passing 
of the Education Act, and attribute this greatly to the fact that 
one eighth of the child population of the country do not appear 
on the books of any elementary schools. There can be little 
doubt that this results from the lax administration of the law 
by the magistrates, and the inherent difficulties of dealing with 
those most in need of school discipline. A hasty judgment 
attributes the outrages of Hooligans to the inadequacy of 
education as a reforming force, and recalls the magnificence of 
the promises of improvement as compared with the poverty of 
performance. It is true that the school boards have been 
captured by the faddists and the incompetent in too many 
instances, that the thorough teaching of elementary knowledge 
has been sacrificed to unnecessary extras, that education in the 
wider sense, as affecting the conduct of life in the light of 
modem science, is almost everywhere an unknown quantity ; 
yet it is to educational institutions that we must look for the 
desiderated improvement in the less favourably placed classes 
of society. It is sufficiently discouraging for those children 
who pass from the comfortably equipped school-house to a 
squalid and deteriorating environment, but these at least are 

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brought into contact with law and order, and shown a more 
excellent way. The waifs and strays who evade the civilising 
effects of such education as is theirs by legal enactment must 
now and hereafter constitute a danger to the State which 
should be averted by every reasonable means. We discover 
no panacea in training the criminal class to read, write, and 
cypher; much more is required to fit their offspring for the 
duties of citizens; in just proportion to our ineffective dealings 
with them will be the resulting danger to the commonweal. 

What can be expected of the truant Hooligan but that he 
shall develop into an habitual offender? And when he has 
reached this stage of his career his treatment is quite as 
inadequate as when he was less capable of mischief. The 
Prison Commissioners state that the tendency to shorten sen¬ 
tences passed upon this class of criminal increases the number 
of them at large, to the public detriment. That is a very 
serious statement and must attract very serious attention. It 
is assuredly high time to call for consideration of the problem 
in face of such an authoritative opinion. No doubt the 
reformatory system has somewhat fallen into disrepute, but 
much good work has been done by industrial schools, and 
many a boy has been saved from vice and disaster by the 
training he has received in them. We require more modem 
methods in dealing with these incorrigible offenders. There is 
necessity for an intimate oversight of the children of degraded 
parents, there is further necessity for classified prisons which 
shall be truly reformatory institutions where prolonged deten¬ 
tion shall be really salutary to the criminal as well as beneficial 
to the general public. 


Punishment of the Insane . 

The modem treatment of insanity has been developed from 
the basic fact that the insane are not responsible for their 
actions. Hence it arises that an asylum is a school for all the 
Christian virtues. Forbearance and kindliness, fortitude and 
forgiveness, resolute‘patience and temperate conduct are incul¬ 
cated on all who hold positions of trust in our institutions for 
the mentally afflicted. Dr. Mercier places this in the forefront 

of The Attendants* Companion : “ Above alk things no attendant 

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must, under any circumstances whatever, strike a patient or 
punish one in any way.” And we have no doubt that he 
would make that necessary rule applicable to every official in 
his dealings with those under his care and protection. How 
comes it, then, that Dr. Noott has been moved to reiterate 
what has been for so long and so definitely accepted as inevit¬ 
able and unalterable ? Is it because Dr. Mercier was determined 
“ to make our flesh creep,” and thus command consideration of 
problems which must be met and decided in courts of justice ? 
We who live within the narrow sphere of asylum routine stand 
in constant danger of ignoring nice points which have to be 
debated in the great world. Dr. Bristowe calls our attention 
to the difficulties of diagnosis, the obstacles to appropriate 
treatment, the grave responsibilities of general practice in 
reference to insanity. These are in great measure settled for 
us on the admission of the patient under all the accumulated 
restraints of a complicated law. If insanity were an entity, 
something which could be weighed and measured with indubit¬ 
able results, these discussions would not arise. But there are 
cases in regard to which a definite decree must be pronounced, 
in regard to which opinion is conscientiously divided, and life 
and death may hang in the balance. It is admitted that the 
youngest of us is not infallible, and as experience grows so 
does judgment become more cautious. We have had wise 
councillors and legal precedent pronouncing for the doctrine of 
partial responsibility ; and in that direction lies more hope for 
the future of the race than in the absolute negation of any such 
possibility. By an acceptance of that doctrine we occupy a 
position enabling us to plead for the reformatory treatment of 
habitual drunkards and instinctive criminals, for those who by 
heredity and environment and habit are so deteriorated in 
mental condition that they drift on the borderland of insanity. 
It is for courts of justice to condemn to punishment, and to 
reduce punishment to proportions appropriate to whatever 
extenuating circumstances may have been proved in evidence. 
The medical profession has nothing whatever to do with these 
awards of rightfully constituted authority. Medical witnesses 
are entitled to a respectful hearing, and to afcareful consideration 
of their evidence only in so far as they speak that they do know, 
and testify that they have seen. Until their science is perfect 
we see, fortunately, no chance of their being constituted judge 

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and jury. In disputed cases, where there is room for difference 
of opinion, the grave responsibility of deciding lies with those 
who have been trained to sift evidence, and those who have been 
approved by their professional forensic skill. We do not agree that 
medicine should trespass on law. 

No doubt, as Sir Henry Maine admits, social necessities and 
social opinion are always more or less in advance of law, for 
law is stable and society is progressive. When we are in a 
position to show how the law may be improved, our duty will 
be clear. Meanwhile we, as an association, have but lately de¬ 
clared that we have no suggestions to offer. 

Let us clear our minds in regard to Dr. Mercier’s position. 
He urges that deprivation of awards in asylum life constitutes 
punishment Naturally that is forcibly and indignantly denied. 
Perhaps he has been looking up Mark Twain’s legal studies, 
wherein it is proved that the intention constitutes the crime, and 
perhaps his next excursus will be yet more horrific. Meanwhile 
his use of the word, which inevitably suggests retribution in the 
Mosaic sense, as applied to the ordinary methods of asylum 
treatment cannot but irritate. Medicine is concerned with treat¬ 
ment, it has nothing to do with revenge. A turbulent patient 
may be severely punished by a blister, and may even regard its 
application as a proof of vengeance, while the physician is 
satisfied that it is necessary and proper irrespective of any out¬ 
rage which may have been committed. He has to correct 
patients, to make right what has been wrong ; he has to disci¬ 
pline patients, to instruct them, and to regulate their actions ; 
he is debarred from punishing patients in the sense of inflicting 
pain and measuring out retribution. It is absolutely necessary 
to make considerable mental reservations in applying the term 
punishment to the withholding of awards. If we grant that 
this is punishment how severely is the average man treated when 
he is slighted by Fame and Fortune ! Indeed, in pursuing this 
vein of thought we begin to feel acutely wronged since none of 
us has been ever yet honoured with a K.C.B. 

The invidious meaning of the tabooed word is well brought 
out by Addison, that master of the English language: “ When 
by just vengeance impious mortals perish, the gods behold 
their punishment with pleasure.” 

We positively cannot picture Dr. Mercier a party to these 

spiteful pleasures of imperial Jove, whether the impious mortals 

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are adjudged sane or insane; and, while agreeing with Mr. 
Herbert Spencer that “harmonious co-operation, by which in 
any society the greatest happiness can be attained, is made 
possible only by respect for one another’s claims,” it falls to the 
asylum physician to induce that co-operation amongst anti¬ 
social units not by the process of punishment, but, again in the 
words of that great master, “ by the regulation of conduct in 
such a way that pain shall not be inflicted.” And our position 
is that our ordinary institutions are unsuitable for dealing with 
those of strongly marked anti-social proclivities threatening 
great risks to the community, but that these should be dealt 
with in special asylums provided by the State. 


Lunacy in New Zealand\ 

The condition of the asylums in the colony of New Zea¬ 
land seems from the report of Dr. Macgregor to be in a most 
unsatisfactory condition, as will be seen from the following ex¬ 
tracts. The total number of registered lunatics in the public 
asylums at December 31st, 1897, was 2386. The admissions 
in 1897 were 532. The increment for the year was 108, and 
it is foreseen that there will be well over 100 added each year. 
Certain work is in hand, but if that were now finished and 
occupied, there would still be a deficiency of room for 158 
patients ; in other words, there are now 234 patients in excess, 
which will be reduced to 1 5 8 sooner or later ; but meanwhile 
patients are added at the rate of 100 per annum, and there is 
no further accommodation in sight. 

The results of such a pressure on space are shown thus : 

“ At Seacliff during the year we had a terrifying experience 
of the evils of over-crowding. During an epidemic of septic 
pneumonia, ten persons died, and in the words of Dr. King, 
their deaths must be credited to the over-crowded state of the 
asylum. 

“ At Seacliff we have been compelled to use the entertain¬ 
ment halls for dormitories, a state of things which only the 
direst necessity can excuse, for it cannot be justified. 

“ At Auckland day after day patients complained bitterly of 
being unable to sleep, and when one finds that a whole dormi¬ 
tory of women is kept awake by one woman in another, it is 

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very distressing to know that one must look on without a 
remedy, when a remedy can with moderate ease be provided. 

“At Christchurch fifty-two male patients (out of 276) in ex¬ 
cess of the dormitory accommodation are scattered all about 
the building, sleeping on shakedowns on the floor.” 

The causes of this crying evil are to a certain extent those 
with which we are familiar in this country,—the sending in of 
old people who are a little troublesome, cannot take care of 
themselves, or have incorrect habits. It is bitterly complained 
that many of these cases might well be taken care of by their 
sons and daughters, who selfishly prefer to tax the country rather 
than do their duty to their aged relatives. There is no further 
room then for the acute cases, and Dr. Macgregor points out: 

“ This being the condition of our asylums, it seems hopeless 
to induce medical men and the friends of patients who are 
showing symptoms of incipient mental disease to commit them 
to our care, when even with our present means much could be 
done in the way of prevention that is impossible without legal 
control in private houses. No man can exaggerate the terrible 
consequences to many unfortunate persons of the natural horror 
of committing dearly-loved friends to institutions which are well 
known to be so over-crowded that their proper treatment cannot 
be hoped for. The early treatment of the mentally diseased in 
many cases offers the only chance of restoring sanity. Many 
for the want of this become hopeless dements for life.” 

There does not seem to be much hope of better things until 
there is a thorough change in the lunacy system of the colony. 
As long as the Government finds not only the buildings but 
also the maintenance, the local ratepayers are not likely to scan 
very closely the fitness of the patients sent in to profit by board 
and lodging. In fact the tendency must be to get rid of any 
one who may require assistance from local revenue. In our own 
grant of 4^. a week for asylum patients, some recognise a mis¬ 
chievous tendency in this direction, but there is the consoling 
fact that if by reason of this tendency the asylum is blocked 
up, those who send in patients on the least pretence of insanity 
have themselves to bear the cost of finding expensive accom¬ 
modation to replace that which is misused. But not only in 
this respect is the present system of New Zealand wrong. The 
Government should under no circumstances whatever be the pro¬ 
vider of asylum accommodation. It should, on theoTh^r hand, 

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OCCASIONAL NOTES. 


[Jan., 


be in a position to insist on the laws, which it has itself passed, 
being obeyed. This it cannot do while it combines in its own 
body both functions. It surely must be a scandalous condition 
of affairs when Dr. Macgregor, its own energetic and able 
officer, feels compelled to publish such appeals as this : 

“If our Parliament would escape the charge of inhuman apathy 
in the treatment of the mentally diseased, they must at once 
insist on sufficient accommodation in our asylums, and as soon 
as possible thereafter they will make separate provision for the 
criminal insane and for idiots and imbeciles.” 

He ought to be in a position to not only warn the Govern¬ 
ment that the insane are not properly treated, but also to receive 
explicit instructions to see that justice is done to them ; and 
further to receive instant support in steps taken for that purpose. 
Lunacy administration should never by any possibility be the 
subject of party attack, and we fear from information received 
from a source unconnected with this question that there is more 
than a suspicion this way. 

Another great advantage of such a change is that Dr. Mac¬ 
gregor himself would be withdrawn from any responsibility in 
the management of the institutions themselves. The whole 
system at present is too involved. Though all parties may be 
working for one good end, yet, as we find in this country, inde¬ 
pendence in office and the powers of criticism incident to that 
independence are on the whole very healthy. The duties of 
the executive authority, of its officer, of the local provider of 
accommodation and of its officer, the medical superintendent, 
must be separated and well defined in order to produce the best 
forms of lunacy administration. On behalf of the latter officer, 
and indeed of all asylum officers, we have to enunciate a prin¬ 
ciple which experience has shown to be incontrovertible,—a 
liberal and just appreciation of their claims is in the end true 
economy. 

While thus strongly urging that adequate measures should be 
at once adopted for the proper care and treatment of those 
afflicted with the most terrible disorder which can incapacitate 
humanity, we do not write in ignorance of the difficulties under 
which the colonial Government labours, and the pressing claims 
on their attention on every hand ; but we feel assured that 
public opinion will not at this time of day suffer neglect and 
parsimony in dealing with the insane. 

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REVIEWS. 


139 


Part II.—Reviews. 


The Fifty-second Report of the Commissioners in Lunacy , England , 
London , 1898. Pp. 468. Price 2s. 2d 


The Commissioners in Lunacy have to chronicle in their report to 
the Lord Chancellor for 1897 an increase of 2607 patients in the 
number of “ officially known insane,” and this increase, though less by 
612 than that of the preceding year, swells the aggregate of lunatics 
within the Commissioners’ cognizance to 101,972, a number sufficiently 
large to cause all interested in lunacy matters the most serious thought. 
Apart from the grave question of adequate accommodative provision for 
so enormous an accumulation of insane—a matter the Commissioners 
very properly dwell upon annually—it is, we think, our duty to enter 
an earnest protest against the inaction of the Lord Chancellor in not 
having, long ere this, augmented the number of active Commissioners 
beyond the three legal and three medical gentlemen who at present 
have to perform three times the amount of onerous duty which their 
predecessors in office, forty years ago, were called upon to do. Why 
the Commissioners should in their annual reports so timorously shrink 
from hinting even at the advisability of an increase in their numbers 
we are at a loss to understand, and it is not entirely on behalf of 
the insane whose detention and proper care they have to supervise 
that we would suggest to them to ask for an increase in their number. 
That the Board performs its work admirably, notwithstanding the 
heavy duties thus imposed, we all know—it is, perhaps, uncalled for 
to utter any such laudation—but it must strike the least observant 
among us that many more years of useful labour could have been 
secured to the State from men who have, as quite recently has 
happened, fallen by the way through illness, the result, it cannot be 
doubted, of the heavily pressing and anxious work through which they 
have had to go. The duties of visitation and report on the existing 
asylums, hospitals, and licensed houses alone are already sufficit nt for 
at least a dozen Commissioners; and when to this arduous and restless 
routine work there are added the innumerable responsibilities of other 
official obligations, it is, to say the least of it, a matter of surprise to 
note how well this small body of workers bears tbe strain. We want 
another social pioneer to preach the evils of overstrain, not in Board 
schools this time, but in the Lunacy Office. The cause of this oversight 
—for such we presume it to be—is no doubt the fact that the authority 
presiding over lunacy matters is never sufficiently long in command to 
properly investigate the needs of the department; perchance a few more 
years of office may rouse the present Lord Chancellor to a revision of 
the constitution of the Board of Commissioners. 

The table dealing with the classification and distribution of this huge 
mass of insane humanity—assuming for the moment that it is good 
statistics to take a censal enumeration of the insane thus—shows that 
the major increase has occurred among paupers, these being 275 per 


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[Jan., 


cent, higher than last year, when the largest known increase had to be 
recorded. That quastio vexata , the increase of insanity in our midst, 
has temporarily been shelved by the more sensible distinction that 
lately has been drawn between a real increase in the number of officially 
known lunatics and a fictitious increase of insanity; and the stirring 
times in which we have lately been living must make us thankful for the 
absence this year in the lay press of those annual irritating diatribes on 
lunacy and its increase. It is only when other sensational matter runs 
short that the daily press expounds its immature and chaotic views on a 
subject of which its knowledge is infinitesimal. 

The summary of insane patients known to the Commissioners on 
January ist, 1898, when compared with a similar summary of ten years 
ago, will give us some clue to the reason of this increase in the number 
of pauper patients. While in 1888 16-3 per cent, of pauper insane were 
confined to ordinary workhouses, the ratio percentage of these in 1898 
was only 11*9, notwithstanding an increase of n’5 per cent, in the 
actual number of insane paupers. The inference to be drawn from this 
is that many more of the workhouse insane are now relegated to 
asylum care, and that the extra attention they there receive tends to 
their longevity, thus diminishing the recovery rate and swelling the 
number of aged paupers in all institutions. 

The tables furnished by the Commissioners in this year’s report differ 
in no great respect from those of previous years, and the same dreary 
columns of figures are served up for the edification of the statistical tyro. 
We last year particularly drew attention to the repetition year after year 
of certain tables dealing with ratios to population, &c., tables which 
serve the purpose merely of misleading the casual reader of this report; 
and we have merely in so doing acted up to our convictions, for we 
cannot be persuaded to the belief that they are serving any really 
good purpose. To others, however, we can give due appreciation. 
No one, for example, can deny that the ratio of insane paupers to 
paupers of all classes, both known quantities taken on the same date, 
furnishes us with the most trustworthy barometer we possibly can have 
of the prevalence of insanity in our midst. Regarding this table, then, 
we find that while the ratio of paupers to estimated population has for 
the last ten years remained practically stationary (ranging between 2.87 
and 2*59 per cent.), the ratio of known pauper lunatics to known paupers 
has gradually increased in the decade from 9^25 to 11*08 per cent. On 
this most interesting table the Commissioners, however, do not venture 
to remark. The increase thus noted has sufficiently frequently been 
commented upon in these pages, and we shall not weary our readers 
with reiterations. The mere recognition of this fact that, notwithstanding 
the great increment per annum of pauper insane (the annual average 
increase being 2373 for the last five years), the ratio shows for the same 
period no larger variation at any time than *98 per cent, of total pauper 
lunatics to total paupers, must be a convincing statistical proof (if 
statistics can prove anything) that insanity is a constant for that section 
of the community. All other ratios of insane to population must, if 
fairly considered, be discarded as fallacious and misleading. 

The total number of admissions into the various institutions for the 


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141 


reception of the insane during 1897 was 19,045, an increase of 191 on 
the previous year’s totals. The following table gives the increase and 
decrease in admissions during the year for the various institutions, &c. 
It will be observed that registered hospitals, which in the previous year 
presented a decrease in the number of their admissions amounting to 
68, have admitted in 1897 57 more patients than in 1896. 



j 

County and 

Borough 

Asylums. 

Registered 

Hospitals. 

Metropolitan 

Licensed 

Houses. 

Provincial 

Licensed 

Houses. 

Naval and 

Military 

Hospitals. 

Criminal 

Asylum, 

Broadmoor. 

Private 

single 

patients. 

Ji . 

« « 

c2 £ 

s£ 

2"= 

Total. 

Increase 

• • 283 

57 

— 

— 

47 9 

2 

— 

398 

Decrease 

1 

. . — 


114 

68 

— — 

i 

25 

207 


Total increase .191 


The Commissioners specially remark on the decrease in the total 
number under treatment in licensed houses, and the remarkable diminu¬ 
tion in the number of their admissions ; but this decrease is very easily 
explained by the larger number of private admissions into county 
asylums, licensed houses apparently no longer granting admission to 
those poorer paying cases which a few of the hospitals, of great 
wealth and specially endowed for this very purpose, have for so long 
neglected. In fact, the essential duties of some of these so-called 
charitable institutions for the insane seem now to have been taken 
over by county and borough asylums, hospitals being left a free 
hand more efficiently to compete with private asylums for well-to-do 
patients, unhampered by restrictive licences. Certified private patients 
appear from this table and last year’s to be steadily on the decrease, and 
such a state of things cannot surely be wondered at while the law is 
being openly defied in the matter of the reception of uncertified insane 
into private residences. 

The readmissions on fresh reception orders due to the expiry of 
previous reception orders are, as we predicted would happen five years 
ago, on the up-grade. The labour which this statutory obligation 
entails would have been simplified, for the Commissioners at all events, 
had the Act demanded an annual report on each patient instead of the 
present cumbrous system. 

Recoveries during 1897 numbered 7230, an increase on the recovery 
total of the previous year of 52, and an increase on the average recovery 
total of the ten preceding years of 723. The actual numbers for the 
various modes of care remain remarkably similar to those of the previous 
year. The percentage of stated recoveries to the total number of 
admissions dropped during 1897 to *64 per cent, below the average rate 
of the decade; and if, as last year, we calculate the recovery rate to the 
average number resident, we shall find that the proportion, viz. 9*31 per 
cent., is the lowest for the last twenty years. Why the Commissioners 


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[Jan., 


should give us the calculation of deaths to daily average number resident, 
and not recoveries on the same basis, we cannot quite comprehend. 
The principle on which recovery rates were originally calculated was 
adopted to suit individual asylums, and merely for the sake of com¬ 
paring recovery rates with those of other asylums; and the Commissioners 
have accepted this system as equally applicable to asylums in the mass, 
forgetting evidently that the recovery to average number resident is the 
genuine and the recovery to admissions merely the convenient gauge 
of a recovery rate. Individual asylum statistics certainly would be 
incorrect when, for comparison of its recovery rate with those of other 
institutions, the recoveries to average number resident were set forth 
alone; but taken in the aggregate, and where a year to year comparison 
of the recovery rate of all asylums is only required, it is the best method 
of calculation. The results of the two systems, though frequently 
showing equal variations for certain years, disagree in their quinquennial 
average ratios; for it may be observed that the ratio of recoveries to 
average number resident gives us exactly what we would expect to find— 
a steady and uniform declination in the recovery rate, due, as we pointed 
out last year, to the accumulation in all asylums of non-recoverable 
cases. The rational estimation of recoveries to admissions gives an 
inexplicable variation in its quinquennial averages. Seeing also how 
much closer a bond exists between the actual number of recoveries and 
the actual number resident than between recoveries and admissions, we 
must regard the former as the more delicate and trustworthy measure 
of the proportionate annual cures in all asylums. 


Year. 

Percentage ratios of recoveries 
to admissions. 

Percentage ratios of recoveries 
to average daily number 
resident. 

1878 

39*94 


"* 3 l| 


1879 

4050 


10*96 


1880 

40-29 

- Average 39*97 

IO *77 

* Average 10*75 

1881 

39*72 


10*51 


1882 

39*41 J 


IO*22 w 


1883 

38 ' 5°1 


10*28^ 


1884 

40*33 


10*30 


1885 

4 i *99 

■Average 4010 

989 

- Average 0*92 

1886 

4116 


9*73 


1887 

3856J 


9 ‘ 4 i J 


1888 

387O 


9 * 54 l 


1889 

3881 


9*44 


1890 

3859 

* Average 39*21 

9*87 

* Average 9*90 

1891 

41-04 


10*58 


1892 j 

38-94 j 


1008, 


'893 

38-45] 


9 * 95 l 


1894 

403' 1 


1013 | 


189s 

38-18 

* Average 38*76 

9*78 ( 

* Average 9*74 

1896 

38-53 


9*54 


1897 

38-35 J 


9 * 3 1J 



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1899.] 

The explanation offered by the Commissioners for this declination in the 
recovery rate, viz. that in recent years many more cases of senile dementia 
have been removed to asylums, is apparently a sufficient one when the 
recovery ratio to admissions only is considered; but another factor of 
equal importance, one to which we have drawn attention in previous 
years, which, moreover, is quite lost sight of in their recovery to admis¬ 
sion calculation, viz. the gradual diminishing death-rate in all asylums, 
according to age periods, as age advances beyond fifty, gives us, together 
with such admissions of senile dementia, a better explanation of the 
altered recovery ratio. As both factors are taken into account in the 
rational estimation of recoveries to average number resident, it follows 
that this must be the more reliable method of calculation. 

The total number of deaths during 1897 amounted to 7322, an 
increase over that of the previous year of 516, and this apparent aug¬ 
mentation is due probably to the low rate of 1896, which was the lowest 
in twenty years. This year's ratio of deaths to daily average number 
resident is *25 per cent, below the average ratio per cent, for the last 
ten years. The table of age-period death-rates for the year 1896, 
calculated from some of the tables supplied by the Commissioners, is 
here again given. 


A ge 

Death-rate per iouo 
reported insane, 
1896. 

Death-rate per iooo 
whole population, 
1896. 

Insane to sane proportionate death-rate. | 

periods. 

1896. 

1895. 

1894. ; 1893. 

Under 

5 

5-9 

{£ =} - 
,{£ SI} ** 

{£ %\} •«» 
{?: 8 } « 

: 11 *4 to I 

1 

17*5 to I 

j 

j 

25*5 to i i 8*5 to 1 

1 ! 


2 5-34 { p 

35-44^; 

55 -^ 4 ' { ^ 
65-74 {? 

75-84 {“■ 

[85 and f M. 
upwds.l \ F. 


3 fr 3 

379 


37 * 1 


-{ 

. S} *“{ 

SShH 

in *•*;{ 


60 ‘ 
52 


■?}} **{ 


,S|6 'S V ,®7 

137*6/ 7 

3450 1294*3 
243*7 J^ J 

52T3 \siS‘3 

503 * 4 /° 


M. 

F. 

M. 

F. 

M. 

F. 

M. 

F. 

M. 

F. 

M. 

F. 


n 


2 ' 

2 
3*. 

3* 
4*9 1 
4*3 J 
6*41 
5*9 J 


2*3 16*1 to I 


3*4 
4*3 
61 
101 
i 5 -8 


{p m 

{?. 

a 

s 


5*9 
iro 1 

9*3 J 
17*81 
13*8 { 

32 * 51 
26*4/ 

6r81 
53*0/ 
129*81 
117*2 f 

SIM 


ii* 9 to 1 
13*0 to 1 
10*3 to 1 
7*7 to 1 
4*9 to 1 


28 0 to I 22*9 to 11 25*0 to I 
in to 1114*6 to 1 
11*7 to I! 12* I to I 


u*4 to 1 
9 0 to 1 
ii* 8 to 1 

j 

7*5 to 1: 
5*o to 1 


29*4 

I 

57*4 

123*5 


3*2 to I, 3*2 to I 
2*9 to I, 2*7 to 11 
2*3 to 11 2*1 to I 

i 

2*1 to I 1*5 to I 


10*4 to i 
7*5 to i 
S*i to 1 
3*7 to 1 
3*0 to 1 
2*7 to 1 
i*3 to 1 


8*9 to 1 
7*9 to 1 
5*7 to 1 
3*3 to 1 
2*5 to 1 
2 3 to 1 


Apart from the usual interesting numerical evidence of the variation 
in death-rate according to age periods in persons of unsound mind, 
this table furnishes proofs of the contention to which we have already 


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REVIEWS. 


□an., 

made allusion, that the insane death-rate tends to approximate to the 
sane death-rate as age advances, until in the last few decades of life it 
becomes nearly the same as the sane death-rate. For the sake of com¬ 
parison we have added the insane to sane proportionate death-rates for 
each age period for the years 1893 to 1896. Fluctuations, it will be 
observed, in these proportions occur principally in the earlier age 
periods, when acute symptomatic insanities are more prevalent, while 
the ratio remains remarkably steady lor the mid age and advanced age 
periods. The large proportion of male deaths from thirty-five to sixty- 
four is due, in all probability, to the influence of general paralysis. 

The causes of death are again tabulated, but although the number of 
deaths for 1897, according to Table V, is 7322, the Commissioners 
account in this table of causes of death for only 7298. Now that this 
table has appeared for three years it may be interesting, merely for the 
sake of comparison, and not for any rash deductions, to summarise the 
percentages of the principal causes to the total number of deaths here 
given for each year. 


Causes of death. 

1895. 

1 1896. 

| *897- 

1 

General paralysis ...... 

20*00 

20*41 

! 1897 

Phthisis pulmonalis 

14*88 

; 1 3 'ss 

1 * 4‘57 

Senile decay. 1 

77 i 

, 869 

9 ' 3 I 

Pneumonia. 

701 

6*36 

613 

Cardiac valvular disease . . . . 

478 

573 

6*02 

Epilepsy. 

516 

489 

4*66 

Exhaustion from mania and melancholia 

3'87 

362 

3'*>5 

Organic disease of brain . 

2*60 

3'50 

; 346 

Apoplexy . 

316 

321 

3* x 3 

Chronic Bright’s disease 

2*92 

2*56 

272 

Cancer ........ 

2*01 

2*56 

! 213 

Bronchitis ....... 

2*89 

2*46 

2*09 

Accident . 

*40 

i *42 

*45 

Suicide 

‘25 

! 14 

*28 

Other maladies. 

22*36 

j 2157 

22*43 


The table dealing with the number of patients admitted into various 
institutions during 1896 according to their mental disorders—the Com¬ 
missioners, be it noted, still patronising their ancient “classification ” of 
mental affections—if continued annually for a few decades, may prove 
valuable in giving us some idea as to the correctness of the investigations 
of Parchappe, Esquirol, Aubanel, Thore, and others as to the influence 
of season on the occurrence of insanity, but any deductions from their 
own tables are not yet warrantable. Already has the sweeping decision 
made by the Commissioners last year for 1895 been upset by a variation 
in the incidence of insanity in 1896. 

We regret that we cannot, so long as the Commissioners’ classification 
of mental disorders is maintained, attach much value to Table XXI, 
that showing by a yearly average the forms of mental affection in 
patients admitted into institutions during the five years 1892 to 1896. 
The Commissioners are not, however, alone to blame in this, for our 


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REVIEWS. 


145 


own experience of statements ” and “ reports ” furnished to their 
office by superintendents and managers of asylums proves that this 
unscientific classification is one very widely adopted. We should, how¬ 
ever, be pleased to learn what is meant by “ dementia—ordinary; ” is 
it amentia, stupor, stuporous melancholia, sequential dementia, paralytic 
dementia, imbecility, or what ? There are asylum superintendents who 
regard some one or other of these terms as synonyms of dementia. 
Mania and melancholia, moreover, as we remarked last year, being but 
symptoms, are expressive of so many varied insanities that their grouping 
in this manner gives one but little idea of the prevalence or proportionate 
occurrence of symptomatic and true insanities. J t would certainly be 
gratifying were all reports to the Commissioners’ office so framed as to 
give a more definite value to the varieties of mental affections beyond 
the elementary and unsatisfactory division into exalted, depressed, and 
impaired mental slates. Were this done we should probably find 
** other forms ” showing a much higher percentage ratio than at present. 
Table XXIII certainly gives us some clue, so far as epileptics and 
general paralytics are concerned, and from this we gather, comparing 
the percentage proportion for the five years 1892 to 1896 with that of 
the preceding quinquennium (if a deduction can with propriety be 
drawn), that general paralysis appears to be making no serious advance 
in the proportionate number of those admitted to asylum care, while 
the proportion of pauper and private general paralytics is almost identical 
for the past five years, the antecedent five years having shown an excess 
of 2*1 per cent, of pauper over private cases. One cannot help being 
struck in looking at this table by the vast preponderance of female 
paupers over female private general paralytics (the former being 3*5 
times as great as the latter), and this is no mere statistical accident, but 
proof of a clinical observation that general paralysis occurring in women 
affects the lower strata of society more than the upper, and especially 
those subjects who have been infected with syphilis. 

Intemperance in drink maintains its stated influence as an exciting 
cause of insanity, and the quinquennial percentage proportion to yearly 
average shows an advance on the previous five years’ percentage of ri 
per cent, for males and *8 per cent, for females. We cannot, however, 
accept the figures as to the influence of “ venereal disease f surely a 
more careful investigation into the previous histories of patients should 
reveal in so wide-spread an affection a larger percentage than r8 for 
males and *5 for females. The table (XXV) is one open to many other 
serious objections and can only be accepted as an approximate estimate 
of the causes of insanity, for reasons we have dwelt on in previous years ; 
and this remark applies with greater force to Table XXVII—that 
dealing with the causation of general paralysis,—which conveys no 
trustworthy information whatever, for the percentages are nearly the 
same as those of other insanities. We had no knowledge until looking 
over these tables that heredity was so prominent a factor in general 
paralysis. Clinical and pathological evidences as to the aetiology of 
this disease are quite at variance with this table. 

The information obtainable from Table XXXI as to the yearly average 
of suicidal cases among the single, married, and widowed inmates of 


XLV. 


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146 


[Jan., 


asylums, serves as material for the cynic, for married males appear to 
be the most numerous. 

We have purposely this year refrained from commenting upon some 
of the statistical tables of this report, though our conviction remains 
unaltered. When we compare the information gleanable from foreign 
official reports with that so sparsely supplied in our own, we can but 
confess that we are lagging grievously behind the times. 

We are aware that the abstract of accounts of the registered hospitals 
given in Table X of Appendix B is not one from which trustworthy 
conclusions can be drawn, but we cannot help noting from the figures 
supplied how pitifully some of these hospitals fail in carrying out the 
charitable element of which they pose as the champions. Hospitals 
which on their own showing have a surplus of receipts over expenditure 
of 43, 26, and 21 per cent., while their average weekly receipts per head 
come to j£z'7 2, ^2*79, and ^2*46, cannot be doing much for the many 
deserving poorer class patients. 

The number of boarders continues to preponderate in registered 
hospitals, 195 having been received during the year in eleven of these. 
Manchester Royal Hospital admitted 53, and Holloway's Sanatorium 77. 
Of the total number 62, or 317 per cent., had to be certified and de¬ 
tained as patients; one committed suicide and four dud. Can it be 
that these figures indicate that many boarders are received into insti¬ 
tutions merely to escape the trouble and publicity of outside certifica¬ 
tion? Which reminds one of the recipe for hare soup—“First catch 
your hare.” 

The admissions during 1897 into the 74 county and borough asylums 
amounted to 16,447, or 2 3 l 7 * n excess of the oecennial average. Of 
these admissions 16*1 per cent, were patients readmitted into asylums 
from which they had previously been discharged. The recoveries 
came to 6189, a,) d the deaths to 6659 ; in 5548 (according to Table XV), 
or 83^3 per cent., post-mortem examinations were made. The Commis¬ 
sioners give the percentages of post-mortem examinations made for 
1897 and 1896 as 79 3 and 79*4; our calculations from their own 
figures make the percentages 83*3 and 79*9 respectively. 

The very satisfactory evidence of the vigilant care with which the 
large numbers of suicidal cases in county and borough asylums are 
supervised cannot be passed over without favourable comment. On 
going through the eleven suicides which occurred during the year, one, 
we find, was committed prior to admission, two occurred during leave 
of absence, and of the remaining eight four were certainly not due to 
any culpable neglect; so that only four suicides out of a probable 
61,909 suicidal cases (calculated from the Commissioners' figures) can 
thus be entered as the result of want of due care. Five of the eight 
suicides were by hanging, one was the result of a cut throat, one due 
to scalding, and one to swallowing foreign bodies. The accidental 
deaths numbered fifteen, six of which were either directly due to or 
accompanied by fracture of ribs ; only two died from suffocation during 
epileptic fits, one from impaction of food in the gullet, two from 
injury to or rupture of the bladder, one each from fracture of the 
skull and jaw, one from poisoning by yew leaves, and one from injuries 


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inflicted by a fellow-patient. There is one eminently satisfactory item 
in this list, the small number (only two) of deaths from suffocation 
during epileptic fits. 

Pilloried in the insanitary list there are no fewer than twenty-one 
county and borough asylums (one of these has figured in this category 
regularly for the last eight years, one appears six times in eight years, 
another five times, and so on, the names recurring with unpleasant 
persistency), and it would certainly be of value could the Commissioners 
give particulars of the sources of water-supply, the state of the drainage, 
and the methods of sewage disposal of these asylums in which evidences 
of insanitary condition so frequently recur. 

Table XIII, Appendix B, which is new, presents information as to 
the “ care and treatment of patients in county and borough asylums,” 
though such diverse particulars are recorded as the percentages of 
epileptics, general paralytics, post-mortem examinations (this can hardly 
be classified either as “ care ” or “ treatment ”), bedsores found post 
mortem, chapel, entertainment, exercise and employment percentages, 
and the length of service of attendants. The column dealing with 
general paralysis shows in a measure how this affection predominates in 
seaport towns and industrial centres, but the bedsore column is rather 
misleading, it being scarcely logical to infer that, because in one asylum 
22*0 per cent, of post-mortem examinations revealed the existence of 
bedsores against o per cent, of another, the latter bestowed so much 
more care on its nursing. 

Broadmoor is a State asylum or prison for criminal lunatics, and so 
should escape ordinary criticism, but the custom that obtains there of 
permitting self-st elusion is for such an institution a peculiar one, on 
which the Commissioners remark that “patients who could not 
thoroughly be trusted should not have access to single rooms, where 
they could shut themselves in and escape observation,” this being their 
comment on a suicide by hanging, an exactly similar case having occurred 
in 1896. 

In their remarks on licensed houses generally—there are, by the way, 
71, and not 70 licensed houses—we can cordially second the Com¬ 
missioners’ observations as to the utter absence of all considerate 
treatment by many licensees of the nurses and attendants in their service, 
and it is a matter of little wonder that the nursing staff of the majority 
of private asylums should be so inferior and so constantly shifting 
when inadequate thought is given in many houses to their comfort and 
well-being. The Commissioners consider that attendants or nurses 
sleeping with patients should always have their keys attached to their 
persons at night —experimentum seipsis. From the remarks made 
by the Commissioners in their reports on licensed houses, some licensees 
and managers of provincial houses would appear to be somewhat 
ignorant of the rudiments of modem methods of care and management 
of the insane, and it is just by these few ill-conducted and ill-condi¬ 
tioned establishments that the majority of private institutions are judged 
by the public. The Commissioners surely have the power, or if they 
have it not they should certainly acquire it, of influencing quarter ses¬ 
sion authorities to limit the granting of licences only to such applicants 

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REVIEWS. 


[Jan., 

as have had a proper experience in the management of the insane. 
There would then, perhaps, be less censure and less rancorous denuncia¬ 
tion as to the iniquity of private asylums en bloc\ 

Single patients remain almost stationary in number, and the remark 
made by the Commissioners last year as to the reception of non-certified 
patients could with propriety have been made again; true, the Com¬ 
missioners were able during 1897 to bring one solitary instance to light, 
but there are hundreds pursuing this calling, some having the audacity 
openly to advertise that patients can be received without the necessary 
certificates. 

Two legal decisions from the law officers of the Crown were obtained 
by the Commissioners, one to the effect that a charge above the usual 
14 s. rate may be made by county asylums receiving out-county patients, 
and the other relative to the reception of British subjects in foreign 
asylums. We cannot quote these legal decisions here, but the practice 
of sending British subjects to foreign asylums must surely be due to a 
defect in our lunacy law, and the difficulty present certification entails 
must surely be that defect. 

It is usual in these reviews to pass over without much comment the 
reports on the various public institutions visited by the Commissioners, 
for we have always felt that they have partaken of the nature of con¬ 
fidential communications to the Lord Chancellor as to the working of 
individual asylums ; but though rash, it would perhaps not be unservice¬ 
able to draw attention to this very patent fact, that there are not 
half a dozen asylums in which the Visiting Commissioners have 
not found some ground of fault-finding. Even the most recently con¬ 
structed asylum, the plans of which have just passed the Board, come 
under their adverse criticisms, and we cannot but regard this inclination 
towards censoriousness as an evidence of the overstrain to which we 
alluded at the commencement of our review. 

It was with profound regret that every asylum officer in the country 
learnt of the sudden death of Dr. Wallis. His untimely decease, and 
the recent resignation of Dr. Southey through ill-health, serve as warning 
texts to the authorities that it is time to relieve the active members of 
the Lunacy Board by timely addition to their numbers. 


Fortieth Annual Report of the General Board of Commissioners in 
Lunacy for Scotland. Edinburgh, 1898. Pp. 165. Price is. 3d. 


The total number of lunatics in Scotland under official cognizance at 
the end of 1897 was 14,906, which represents an addition during the 
year of 406, made up of 73 private and 333 pauper patients. The 
increase in the former amounted to 67 in royal asylums, 1 in district 
asylums, and 5 in private asylums ; while pauper patients increased by 
556 in district asylums, and 69 in lunatic wards of poorhouses, and 
decreased by 193 in royal asylums, 86 in parochial asylums, and 13 in 
private dwellings. The total increase in establishments was 419, of 
whom 73 were private and 346 pauper patients, which is considerably 


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over the average for the five years 1891-5. The accompanying table 
shows the total number of lunatics and the manner of their distribution 
on 1st January, 1898. 

The number of private patients admitted was 570, being 88 more 
than in 1896, and 36 more than the average for 1890-4, and the 
admissions of pauper patients amounted to 2713, being 68 more than 
in the preceding year, and 285 more than the average for 1890-4. 

Although a larger number of patients have been discharged recovered 
during the year, taking into account the increased admission rate, the 
recovery rate in all classes of establishments, as is seen in the following 
table, shows a distinctly downward tendency. 


Classes of establishments. 


In Royal and District Asylums . 
In Private Asylums . 

In Parochial Asylums 
In Lunatic Wards of Poorhouses 


Recoveries per cent, of admissions. 

1890-94. 

1895. 

1896. 

1897. 

39 

35 

3<5 

3<5 

38 

26 

40 

32 

43 

46 

4 i 

35 

7 

6 

1 1 

6 

4 


That this is largely due to the altered character of the admissions, 
e . g. the increasing number of cases of advanced years, is very probable; 
and the same argument would apply to the increase in the death-rate 
of this as compared with the preceding year, which applies to both 
private and pauper patients and to all classes of establishments. 


l Classes of patients. 

Proportion of deaths per cent, on number 
resident in all establishments. 


1890-94. 

1895. 

1896. 

1897. 

Private patients. 

76 

6-5 

6*8 

7‘4 

Pauper patients. 

87 

9*2 

79 

85 

Both classes .... 

85 

00 

vi 

77 

83 


Classes of establishments. 


I Royal and District Asylums 
Private Asylums 
Parochial Asylums 
I Lunatic Wards of Poorhouses . 


Proportion of deaths per cent, on number 
resident. 


1890-94. 1895. 1896. 1897. 


88 

84 

76 

8-3 

< 5*3 

108 

1 6 '4 

72 

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Number of Lunatics at ist January , 1898 . 


150 


REVIEWS. 


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1899 -] 


REVIEWS. 


ISI 

The diminished number of recorded accidents and escapes speaks 
more eloquently than anything else could of the increasing care and 
vigilance exercised by all those who are responsible for the welfare of 
asylum patients. Even with the increase of numbers, the escapes were 
fewer by three than in 1896, and the suicides were only four as com¬ 
pared with twelve, while the total fatal casualties only increased by five 
during the year. 

Since 1890 there has been a fairly steady decline in the proportion 
of pauper patients who are accommodated in private dwellings, and this 
has not in any way been checked in the year under review. In their 
report for the preceding year the Commissioners expressed the view 
that this was due to the restriction of licences for more than two 
patients and of the tendency to unduly large aggregations of patients. 
This can only, however, be a partial explanation. Comparing the year 
1890, when the number so provided for attained the maximum of 23*6 
per cent., with 1897, it is found that while the decrease for the whole 
country amounts to i*6, there are six counties, all rural with the excep¬ 
tion of Edinburgh, where increases have taken place, while the remain¬ 
ing counties all record decreases of various amounts from 0*3 in 
Aberdeen to 20^4 in Kinross. Perhaps with more prosperous times the 
economic burden of providing for the insane poor is felt less now than 
formerly; at all events the greater part of the country does not seem to 
be increasingly impressed with the importance of this method of pro¬ 
vision from the financial point of view, and the constantly reiterated 
official recommendation is to all appearance proving insufficient to 
stimulate the local authorities to the further development or even the 
steady maintenance of the system. 

The increase in the absolute numbers of the insane would at first 
sight lead one to suppose that there is a “ growing tendency to insanity 
among the community,” and this supposition would seem to be further 
strengthened by the fact that while the increase of population during the 
year 1897 was only 077 per cent, the total number of lunatics has in¬ 
creased in the same period 2*88 per cent., or in other words the ratio of 
lunatics to population has risen from 336 to 344 per 100,000. These 
facts indicate certainly a growing accumulation of lunacy, but the 
question of greatest moment is not so much accumulation, “ with its 
small social but great fiscal importance,” but, is the occurrence of 
insanity increasing out of proportion to the increase of the population ? 

The proportion of lunatics appearing for the first time on the register 
to population (Table V, Appendix A) has for the past twenty-four years 
been a more or less steadily increasing one, and the ratio for the year 
under review is the highest yet attained, and this might be considered as 
legitimate evidence that there is a disproportionate increase of insanity. 
But the question is in reality a complicated one, and to come to even 
an approximately accurate conclusion there are several factors which 
must be taken into account. 

The increase in the total numbers of the registered insane in relation 
to population, it is generally agreed, is due to simple accumulation, 
brought about by a diminution of the discharge rate among that class ; 
and the apparent increase of occurring insanit^js, there can be little 

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152 


REVIEWS. 


[Jan., 


doubt, to be attributed not to an increasing tendency to mental break¬ 
down among the people, but chiefly, if not entirely, to these two causes,— 
an increasing disposition to transfer unregistered lunatics to the regis¬ 
tered class, and to include under the designation of lunacy cases which 
in former years would not have been regarded as coming within the 
limits of certifiability. 

The same tendency to bring the unregistered within the official 
cognizance in all probability applies to Scotland as it does to England, 
where the percentage proportion of the unregistered to total insane 
diminished in the intercensal period 1881-91 from 13*5 to 10*9, and this 
would go a long way to explain the apparent increase. 

One of the points which has an important bearing upon the question 
is the a^es of the insane at the time of their admission, and this is very 
exhaustively dealt with by the Commissioners in this report. The com¬ 
parison that is made between the admissions of the two years 1885-6 
and 1896-7, though it would no doubt have been more valuable had 
longer periods and larger numbers been taken as a basis, goes to show 
“ that a greater number of lunatics are, from whatever cause, being sent 
to asylums; that as regards private patients the increase is confined to 
persons of middle and advanced age, and as regards pauper patients, 
that though the numbers admitted have increased at all ages, much the 
greater proportion of the increase is contributed by persons of middle 
and advanced age.” It is more than questionable that old age is in 
these later years more liable to mental breakdown than formerly. 
Rather is it that the limits of certifiable insanity are being gradually 
widened and made to include cases which were not until recently 
regarded as requiring asylum treatment. Constant reference is made 
to this change in asylum reports. In England the proportion of first 
attacks per cent, of admissions has in the past five years increased from 
70 to 70*6 ; and that a large amount, if not the whole, of this increase is 
due to the inclusion of senile cases is proved by the fact that old age as 
an assigned cause of insanity in the same period increased from 5*5 to 
6’5 per cent, of patients admitted. 

Once this source of increase becomes exhausted, and unless other 
causes arise (e.g. the relegation of all violent anarchists to asylums as 
dangerous lunatics, as Dr. Samways recently and quite soberly suggested), 
there ought to be a noticeable improvement in the lunacy records of 
the country. Dr. Rayner as far back as five years ago ventured to 
express the opinion that insanity in reality was not even remaining 
stationary, but was actually diminishing; and a careful examination of 
the statistics of recent reports would lead one to the conclusion that 
his view is likely to prove correct. The five years ending 1896, for 
instance, have been characterised in England by a steady diminution in 
the proportion of general paralysis, which in the preceding fifteen years 
had been steadily increasing, and these are cases which occur practically 
only in the prime of life. And, again, the puerperal state, which applies 
equally to the same life-period, figures less and less as a cause of 
insanity, and that in spite of the fact that there is no diminution in the 
number of deaths in the community generally from puerperal fever and 
other accidents of childbirth. That this change, which is noticeable 


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1899 ] 


REVIEWS. 


153 

in England, has yet commenced in Scotland is not quite so apparent. 
The proportion of admissions to population in the former is during the 
past three years a diminishing one, while in the latter it is the reverse. 
But, on the other hand, the proportion of general paralytics who have 
died in asylums is sensibly less in 1897 than in the preceding year, when 
it appears to have attained its maximum. 

The increase of lunacy is, as one would expect, very far from uniform 
throughout the country, and the remarks which the Commissioners make 
in comparing the absolute numbers of 1897 with 1896 do not give us 
much insight into the changes, if any, that may be taking place as 
regards increasing tendency or otherwise to insanity in the various 
counties. Dividing the whole country into three groups of eleven 
counties each, it is found, on comparing Table 18 of Appendix A of 
this report with that of the report for 1887, that of the eleven counties 
which show the greatest increase of the average numbers intimated as 
pauper lunatics over periods of ten years, seven belong to the north, 
and four are lowland; while of the eleven in which the increase is less 
than, or equal to, the general average, seven are lowland and four are 
highland. The county which shows the worst record in this respect 
is Elgin, while at the other extreme is Peebles. The association of 
Peebles and Pleasure is traditional, and who shall say if this further 
association of sanity and pleasure is mere coincidence? Pleasure—the 
Peebles variety—and level-headedness are here shown going hand in 
hand. We confess our ignorance of the precise nature of this Peebles 
pleasure, and we do not by any means wish to suggest that it is 
synonymous with whisky, but nevertheless it is an undoubted fact that 
those counties where drunkenness is most prevalent are exactly those 
where lunacy is least rife. 

The improved condition of affairs as regards mental health, which, as 
noted above, applies to the lowland counties where the industrial classes 
predominate, bears out a view which we have already had occasion to 
express, viz. that it is in those parts in which the lunacy rate is already 
a low one that further improvement is more likely to be effected. The 
tendency is for the energetic and fit to desert the poorer localities, 
leaving the relatively unfit behind, and to seek the industrial regions 
whtre labour and higher wages are assured; and it is difficult to see 
how the increasing lunacy of the rural and isolated parts of the country 
with their undiminishing stagnation of population is to be remedied. 
In the industrial parts, on the other hand, a change in the direction of 
betterment, mental and physical, has, we think, been taking place in 
later years, and is beginning to make itself felt. That we have in 
cycling, in football, and in athleticism generally, which have of late 
years taken such hold upon industrial communities particularly, 
agencies which ought to go a long way to counteract the acknowledged 
evils of urban and industrial life, hardly admits of doubt, and the 
indications of an improved and improving condition of affairs con¬ 
tained in this report lead us to believe that the years to come will be 
marked by a progressive improvement in the mental health of the 
inhabitants of the more populous areas, an improvement which may 
possibly be more than sufficient to counte rbalance the retrograde 
tendency of the more rural parts of the country. 

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154 


REVIEWS. 


[Jan., 


Forty-seventh Report of the Inspectors of Lunatics , Ireland , for the year 

^ 97 - 

Novelty is not a feature which is to be looked for in a Lunacy Blue 
Book. Much the same dry facts, much the same still drier figures, have 
to be stated and commented on. It requires a cook of quite exceptional 
culinary genius to serve up the same ingredients continuously in pala¬ 
table form. And mental pabulum, such as is supplied in reports of this 
kind year after year, becomes at length rather insipid, and palls upon 
the intellectual palate. In this latest report of the Irish inspectors there 
is a good deal of mere reiteration with a few changes of figures. We 
notice, however, one small concession, which may be regarded as the 
rt von o. of this particular issue, in the shape of a short table giving the 
admissions from workhouses into district asylums for the past eight 
years. It may not be overstepping the bounds of modesty if we sur¬ 
mise that the introduction of this table was suggested by some remarks 
on the subject which we ventured to make in reviewing the Inspectors’ 
report for 1896. If so, w r e are grateful, and in any case we welcome 
this table as a useful one, and—dare we hope it ?—as an instalment of 
an improved system of statistical tables altogether, in which, as we urged 
last year, the figures should, as in the English tables, be given for a 
series of years, from which comparisons and deductions could be drawn, 
and not merely the numbers for a single year, which—standing by 
themselves—as a basis for founding conclusions upon are absolutely 
valueless. 

Even in this table the very point which it might be calculated to 
clear up appears to have been overlooked. Within recent years there 
has been a general and well-grounded impression that the number of 
transfers of insane patients (uncertified of course) from workhouses to 
asylums has considerably increased, and that this fact accounts, at least 
in j art, for the continued increase of patients under detention in 
asylums, while not at all denoting an increase in insanity. Certified 
insanity has increased at the expense of uncertified, that is all. That 
this is a correct inference is supported by the statement of the Inspectors 
that “in 1880 the ratio of insane in district asylums to the total 
number under care was 67 per cent., and in workhouses 27 per cent. 
In 1897 the ratio in asylums had risen to 75 per cent., while in work- 
houses it had fallen to 21 per cent.” More precise data, however, are 
required to make this inference a certainty ; and these are furnished in 
the table under review, according to which, on the computation of the 
Inspectors, 14 per cent, of the admissions into asylums during the 
period 1890 to 1897 were transfers from workhouses. But this calcula¬ 
tion in globo does not show whether these admissions denote a progressive 
increase; and that is just the point which it is desirable to ascertain. 
This information can be supplied by an additional column to the table, 
giving the percentage of admissions from workhouses to total admis¬ 
sions for each successive year. The return thus completed reads as 
follows: 


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1899 ] 


REVIEWS. 


155 


Year. 

Total number 
of admissions. 

Admissions from workhoi 

First admissions. Readmissions. 

' 

ises. 

Total. 

j 

Percentage of 
workhouse 
admissions to 
total admissions. 

1890 

3,095 

306 

90 

396 

12-79 | 

1891 

3,010 

297 

84 

381 

12*65 

1892 

3 ,181 

329 

94 

423 

I 3'29 

>893 

3,207 

349 

89 

438 

» 3<55 

1894 

3,229 

376 

84 

460 

1424 

1895 

3,216 

413 

75 

488 

15,7 

1896 

3,329 

459 

89 

548 

I646 

1897 

3,285 

435 

111 

546 

I662 t 

Totals . 

1 

25,552 

t 

2,964 

716 

3,680 

« 4 ' 3<5 | 


From the last column it will be seen that the proportion of transfers 
from workhouses has increased from 12*79 * n I ^9° *° *6’62 in 1897, 
denoting a rise of close on 30 per cent, in eight years. That there has 
been, therefore, a progressive increase in the number of patients 
transferred from workhouses to asylums may be regarded as an estab¬ 
lished fact 

In connection with these figures, however, there is one possible source 
of fallacy. Of late years there has been an increasing tendency on the 
part of relatives, in order to save trouble and expense to themselves, to 
send insane patients to the workhouse infirmaries, on the pretext of 
illness, and then leave it to the union officials to have them certified 
and sent on to the asylum. Such patients are not, of course, workhouse 
patients at all, properly speaking. This fact, to a certain extent, but 
probably not largely, discounts the increase as shown by the above 
table. 

We subjoin the usual summary showing the number and distribution 
of the insane in establishments on the 1st January, 1898, as compared 
with the preceding year. 



On 1st January, 1897. 

On 1st January, 

1898. 


Males. | 

Females. 

Total. 

Males. 

Females. 

Total. 

In district asylums 

7,680 

6,361 

14,041 

7,945 

6,653 

>4,598 

In Central Asylum, Dundrum 

>45 1 

20 

165 

150 

20 

170 

In private asylums 

318 

358 

676 

325 

366 

691 

In workhouses 

1,636 

2,356 

3,992 

1,657 

2,373 

4,030 

In prisons. 

— 

— 

— 

1 

2 

3 

Single Chancery patients in un¬ 







licensed houses 

45 j. 

47 

92 

49 

49 

98 

Totals . 

l' 

9,8241 

9,142 

18,966 

10,127 

9,463 

1 >9,590 

1 


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REVIEWS. 


IS6 


[Jan., 


The total increase for the year was 624, which was again in excess 
of the increase in the previous year, 609. By far the largest part of 
this occurred in district asylums, 557 ; but there was a decrease in the 
number both of total admissions and of first admissions into these 
institutions, the former by 44 and the latter by 13. But this has 
occasionally happened (now for the fourth time during the past ten 
years), and has no significance whatever. The daily average has risen 
from 13,735 in 1896 to 14,340 in 1897, an increase of 605, which is less 
than the corresponding figure for 1896 by 48. No favourable nference, 
however, can be drawn from this. The daily average has increased 
largely during the past three years, which show an increment of no less 
than 1735, whereas that for the previous three years was only 961, not 
much more than half. And if we examine the figures for the past twelve 
years we find that the average increase for the first three years was 303, 
for the second 317, for the third 320, and for the last 578. From the 
record of daily averages we are, then, reluctantly compelled to admit 
that the aggregate of insane under detention is not only on the increase 
but largely on the increase, and there is nothing to indicate a cessation 
of the process in the near future. According to the last census there 
were nearly 5000 lunatics and idiots at large, and there are at present 
some 4000 in workhouses, and until these, or at least all of them who 
can be legally certified as insane, become so certified, we must expect a 
substantial increase in the amount of registered lunacy with each suc¬ 
ceeding year. Two things, and two things only, so far as statistics 
enable us to judge, are likely to put a limit to the progressive increase 
of insanity, using the phrase in the popular sense; and these are the 
complete absorption of the uncertified insane into the ranks of the 
certified, and an increased mortality in the inmates of asylums owing to 
a large number of them having reached an age when death would 
naturally terminate their existence. That this condition must be 
reached sooner or later may be regarded as an absolute certainty, 
otherwise there would be no limit to the increase of insanity. 

This conclusion is, of course, based on purely statistical grounds, 
and on the assumption that pretty much the same number of persons 
will continue to go mad every year. But there is just a possibility 
that public opinion and practice may eventually become sufficiently 
enlightened to take deliberate measures to control the causes of insanity. 
And in this direction lunacy reports might be made to render valuable 
aid. These reports are made nominally to the Lord Lieutenant, but in 
reality to the nation at large. They are reviewed in the press, and 
occasionally articles a e written upon them in some of our periodicals. 
By this means the information conveyed in them is distributed amongst 
a somewhat larger circle of the public than the very small minority who 
read the reports themselves. It is not usual, no doubt, for writings 
of this class to take a didactic form, and yet to whom can the 
public—the public who are constantly clamouring about the increase 
of insanity, and demanding an explanation - look more appropriately 
for enlightenment than to the highest officials of the department. A 
note of warning, authoritatively given and with no uncertain sound, 
as to the folly of imprudent marriages, and unbridled indulgence in 


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1899 ] 


REVIEWS. 


1 57 


drink, tht two great prime and essential causes of insanity, might 
have a salutary effect. Not once nor twice should such warning be 
given, but it should be repeated again and again and again, with 
that “persistent iteration” by which alone unwelcome truths can be 
forced on public attention, until at length people would be led to 
understand the full significance of their own responsibility in the 
matter, and could no longer plead ignorance, nor shift the blame off 
their own shoulders, for at least a considerable share in the growth 
of this enormous evil. The mere publication of a table giving the 
number of cases in which heredity and intemperance were assigned 
as causes is sure to be barren in results, and a mere handful of 
people ever read it. A weighty pronouncement, coupled with some 
words of warning in earnest and forcible language, and inserted in 
the body of the report, would not be inconsistent with the official 
character of the document, and might have a widespread influence 
for good. It is absolutely certain that insanity is originated and 
perpetuated by the two causes above mentioned. It is equally 
certain that both are largely under the control of men themselves, if 
they would only exercise it. It is nothing more nor less than a 
public duty of the first importance that every official in the service, 
from the highest down, who is cognizant of the facts, should bring 
them prominently, and with untiring persistence, before the notice of 
the public. 

Not long ago we read of a society founded in America, the 
members of which—ladies only—bound themselves under a solemn 
obligation never to marry into any family in which there was a 
hereditary tendency to cancer, tubercle, drink, or insanity. “Love 
laughs at locksmiths,” and it is possible that some of these fair folk 
may have found their fortitude give way under the pressure of cir¬ 
cumstances, but, at any rate, it was a well-meant effort on their part 
to stem the progress of disease and maintain the vigour of their 
race. It would be nothing short of Utopian to hope or expect that 
such views will ever become universal It might not be desirable, 
it would certainly inflict hardship and sorrow on thousands, if such 
principles were carried out to their fullest consummation; but it is 
hardly to be denied that if generally, or even partially followed, after 
one or two generations this would have the effect of averting an untold 
amount of suffering from the human race. 

While on this subject of the causes of insanity, we must protest 
against the absolute uselessness of Table XIII, “ Showing the probable 
causes of insanity in the patients who were admitted into district asylums.” 
It is worse than useless, it is misleading. Some years ago this table 
consisted of two columns, one giving the predisposing, the other the 
exciting cause. For some incomprehensible reason this form was 
abandoned, and one cause only allowed to be stated in each particular 
case. Now any one with even a moderate experience in insanity knows 
perfectly well that rarely, if ever, is an attack due to a single cause, and 
hence where two or more causes are operative, an asylum superintendent 
when making the return has to select which of them he considers to 
have been most potent, and enter it as the sole cause. Take a case, for 


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REVIEWS. 


[Jan., 


158 


instance, where an attack of insanity is due, as it so frequently is, to a 
combination of heredity and drink. Which is to be assigned as the 
cause ? One man considers heredity the more potent factor, another 
drink, and each makes his entry accordingly. The result is that dis¬ 
crepancies of the widest description are found under the various 
headings in the returns from different asylums. It is scarcely credible 
that heredity should exist in hardly 7 per cent, of the cases admitted 
into one asylum (Ballinasloe), and in 38 per cent, in the case 
of another (Richmond); or that only a little over 3 per cent, should 
be due to tirink in some districts, as in Monaghan and Sligo, while the 
proportion in the Richmond Asylum and Enniscorthy was 18 and 21 
per cent, respectively. It would be preposterous to draw any inference 
whatever from such figures. The only rational method of recording 
the causes of insanity is to enter every contributory cause for every case 
where ascertainable, and the sum total under each etiological heading 
will give the true record of the number of cases in which any one cause 
was alleged to exist. We would respectfully urge on the Inspectors a 
return to the older form of this table, and in this way they would be 
only following the practice of the English Commissioners. Tables of 
causation are always unsatisfactory owing to the insufficiency of informa¬ 
tion procurable, but it is desirable that we shall obtain as near an 
approximation to the truth as is possible. 

The recovery rate in 1897 was 36*3 per cent, on the admissions as 
compared with 37*2 in 1896, and 39 3 in 1895. This decrease in 
recoveries is what we should expect, as of late years the number of 
senile cases sent to asylums has considerably increased, and in these 
recovery is rare, and as a rule temporary. The rate, as usual, differs 
immensely in the various asylums, ranging from 23 and 25 per cent, in 
Sligo and Mullingar, to 54 and 57 per cent, in Maryborough and 
Carlow respectively. The death-rate averaged 7*6 per cent, on the 
daily average, being lowest in Kilkenny and Castlebar (4*1 and 4*3), 
and highest in Omagh, Letterkenny, and Carlow (i6‘2, ir8, io*i). In 
Omagh the high mortality was due to an epidemic believed to be 
influenza of the gastro-enteric form. 

Three deaths were due to suicide ; two cases of drowning occurred, 
it being doubtful whether they were accidental or intentional; five 
other fatal casualties were recorded, and one death following injuries as 
to which it could not be ascertained whether they had been received 
before or after admission. There were thus eleven deaths in all from 
suicide or accident, as against six in the previous year. In more than 
one of these cases the asylum officials, in the opinion of the Inspectors, 
bould not be regarded as altogether free from blame. The number of 
fatal casualties last year is large for Ireland. There was also an unusual 
number of deaths due to zymotic diseases or affections arising out of 
insanitary conditions, 60 in all. The most serious epidemics were one 
of epidemic pneumonia with typhoid symptoms in Mullingar, influenza 
in Omagh, and a fresh outbreak of beri-beri in the Richmond Asylum, 
which attacked 238 patients and eight members of the staff. The 
symptoms, however, were mild, and the mortality trivial, but it seems as 
if this foreign importation, having once got ingress into the Richmond 


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1899] 


REVIEWS. 


1 59 


Asylum, means to stay. It is surprising that during some of the several 
outbreaks the contagion has not spread outside the walls of the asylum 
into the city of Dublin, and both the citizens and the asylum staff are 
to be congratulated on the restriction of the disease within such com¬ 
paratively narrow limits. 

The number of autopsies increased to 255 from 220 in the previous 
year. The increase is creditable though small We have dwelt in 
former reports upon the many difficulties which attend the advance of 
morbid anatomy in Irish asylums. It must be said that in former times 
this study was not greatly encouraged, and its pursuit did not bring any 
reward proportionate to the time and trouble which it costs. Besides, 
the repugnance felt by the rural population to the bodies of their friends 
being “ opene 1 ” is often very great, and in a country where the people 
cling to old customs and prejudices with an almost pathetic tenacity, it 
may be some time before this feeling is quite overcome. It is to be 
said, further, that few of the Irish asylums are large enough to afford 
room for a special pathologist, and the ordinary staff of an asylum rarely 
contains anyone who can find time or energy for such special work. 
We can hardly agree with the Inspectors’ opinion that the comparative 
infrequency of post-mortem examinations in Ireland is due “ mainly to 
the want of suitable means for carrying out scientific investigation,’’for this 
is itself a result of the other causes. We remember, too, what excellent 
work poor Ringrose Atkins did when he was an assistant with exceedingly 
scanty equipment and without encouragement. We should say that the 
most convenient and the most feasible method of promoting scientific 
investigation in Irish asylums would be to establish three or four 
laboratories, one in each of the large asylums, which would be fed in 
various senses by the smaller asylums as well as by the institutions in 
which they stand. This plan seems to work in an admirable way in 
Scotland, and, as many of our readers know, is contemplated in various 
English districts, where the asylums are not of that huge size that 
enables each to support its own laboratory and pathologist. Outside the 
morbid anatomy of the nervous centres, there must be an immensity of 
work to be done in the Irish asylums in connection with modem aids to 
diagnosis, bacteriological and pathological work, which must be done 
somehow if the institutions are to keep pace with the other hospitals of 
the day, — work which can only be carried out in a well-equipped 
laboratory. Seeing how supremely important scientific investigation in 
these fields has become, this is likely to be soon a matter demanding 
attention. 

The deaths from general paralysis are decidedly on the increase, as 
from a small table in the Report we < alculate that for the three years 
1892 to 1894, the proportion of deaths from this cause to the total 
deaths averaged 2*38 per cent., while in the last three years it has been 
3*9, a rise of 63*8 per cent. The total number of deaths from this 
cause was forty-two, twenty-eight of which occurred in the Richmond 
Asylum. The country districts continue almost free from the disease, 
no deaths being recorded from it in over a dozen of the district 
asylums. 

The deaths from consumption for the past eight years average 27*8^ 


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per cent, on the total mortality. From the figures it does not appear 
that the disease is gaining ground in asylums ; but neither is it lessening, 
as in 1897 the ratio, 31 *4, happens to be the highest in the series, the 
lowest being in 1891, when it was only 24*2. As usual the returns 
under this head show wide variations. In Kilkenny no deaths are 
recorded from this disease, and in Enniscorthy only one, whereas in 
Carlow over 56 per cent, of the total deaths were due to consumption, 
in Cork over 46 per cent., in Sligo and Killarney over 38, and in 
Monaghan over 35 per cent. The other asylums occupy a mean 
position between these extremes. It seem useless to speculate as to the 
cause or causes of such great differences. Soil, no doubt, has a good 
deal to say to it, and in asylums where space is limited the difficulty of 
isolating tubercular patients. But that one asylum should, even for one 
year, be absolutely without a single death from phthisis, and another 
with only one fatality from that cause, is a remarkable circumstance; 
while the fact that in others it accounted for from 35 to 56 per cent, of 
the total mortality looks as if in these institutions some special inquiry 
were needed to discover, if possible, any conditions which might play 
the part of a predisposing or exciting cause. 

The average cost per head for maintenance was ^23 2 s, 7 d., Mullingar 
again heading the list with ^30 12 s., and Ballinasloe bringing up the 
rear with ^18 6 s. 5 d. Castlebar, Kilkenny, and Sligo are all under jQ 20 
per annum. These financial arrangements may be highly satisfactory 
to cess-payers, but unless all commodities are quite exceptionally cheap 
in these districts, it is a question whether justice can be done to the in¬ 
sane in the matter of regime and treatment on such economical terms. 

Of the 3285 patients admitted during the year, 2431 were committed 
on warrant as “dangerous lunatics,” a proportion of 74 per cent. No 
comment is made on this in the body of the Report, but in his report 
on the Ballinasloe asylum the Inspector dwells at some length on this 
subject. He attributes the rapid increase of patients in asylums in 
great part to “ the facility with which the relatives or friends of persons 
showing any degree of mental aberration or degeneration can procure 
their transfer to the district asylums, under the provisions of the 
Dangerous Lunatic Act, 30 and 31 Vic., cap. 118,” and then he goes 
on to say: “ Now, what is the usual procedure in this country ? An 
information is sworn in accordance with the 10th section of 30 and 31 
Vic., cap. 118, before two justices; a medical certificate is given that 
the patient is dangerous, and a committal order is made out. All this is 
so simple and convenient in practice for the relatives of alleged lunatics 
desiring their detention in lunatic asylums, that it has entirely super¬ 
seded the admission form which requires the sanction of the governors, 
although there is no pretence that the majority of persons committed 
under the Act are in any sense ‘dangerous,’ other than that all, or 
nearly all lunatics may be, or may become, dangerous. It is clearly 
undesirable that so many lunatics should be described as specially 
dangerous, who are not properly so; and it is, in my opinion, in many 
respects a most unfortunate procedure that so many of the insane are 
in this country sent to lunatic asylums on committal warrants instead of 
* House ’ forms.” 


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A most unfortunate proceeding no doubt, but one that nothing but 
an Act of Parliament can remedy. And the expression of opinions of 
this sort in an asylum report, however true and applicable they may be, 
will have no more effect, we fear, than beating the air. We commented 
at some little length in our columns last year on this anomalous feature 
in Irish lunacy administration, and any further observations on the 
subject would probably be as much thrown away as if they were 
delivered in the same medium as that selected by the Inspector. But 
it does seem strange that although this evil system has been condemned 
by every authority who has ever written upon it, including a Parlia¬ 
mentary commission, so far absolutely nothing has been done, not a 
single step taken towards its abolition, and the Inspectors seem only 
able to sit as passive onlookers at a system upon which they never tire 
of passing wordy condemnations, while, as far as action in the matter is 
concerned, their hands seem tied or powerless. Is this non possnmus 
attitude to go on indefinitely? We can scarcely believe that if the 
matter were taken up in right earnest a short Act could not be passed 
through Parliament assimilating lunacy procedure in this respect to that 
which obtains in England and Scotland. It is not an unreasonable 
supposition that the Lunacy Office is the proper place for the initiation at 
least of reform in lunacy practice. And when a system such as this has 
met with universal condemnation we confess to feeling a craving to 
know who or what is the obstacle to its abolition. The Inspectors, 
notwithstanding their numerous references to the subject in their 
annual reports, leave us completely in the dark as to whether any or 
what measures have at any time been taken with a view to bringing 
about the desired result, and in the absence of such information we are 
almost compelled to the conclusion that official inertia is at the bottom 
of it all. One thing is certain, as long as the present Act continues in 
force, and as long as human nature remains the same as it always has 
been, no amount of exhortation, nothing that anyone can say, either to 
magistrates or people, will have the smallest effect in preventing or 
even checking the results which naturally flow from such a piece of 
legislation. 

The Inspectors note some improvement in the treatment of the 
insane in workhouses, but only in some of the unions, particularly as 
regards the appointment of trained nurses to supervise them; and in 
some workhouses the lunatic wards have been provided with a better 
class of furniture, hair mattrasses having been substituted for straw, and 
in a few instances even woven wire has been introduced. The sanitary 
arrangements have been improved, water-closets, lavatories, and a bath 
having been provided in several unions where they did not exist before. 
Boards of guardians have actually been known to supply delft chamber 
utensils for the dormitories although why in one case the male patients 
alone have been accorded this luxury, and in another only the females, 
it is not easy to understand. Possibly it might cause too great a shock 
to carry out such a radical reform on too extensive a scale! Fcstina 
Unte — lentissime —that is the guardian’s motto. However, he has 
shown himself capable of recognising the need of endeavouring to 
ameliorate the lot of the hapless folk under his charge, and we will hope 
XLV. II 

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that his ideas and his charity will expand as time goes on. But that 
there is a large field for the further development of the humane treat¬ 
ment of the insane in workhouses is quite clear from numerous entries 
in the several reports, such as that their condition is unsatisfactory; 
wards over-crowded, dark, and unventilated; exercise yard cheerless 
and depressing; only place for exercise is a narrow yard, surrounded by- 
high walls and buildings, without a tree or a blade of grass ; cells with 
flagged floors still in use; old wooden bedsteads, some of the old 
“ harrow ” pattern, with straw ticks ; no fixed bath ; no hot water supply 
for bath ; sheds for day-rooms ; bedridden cases in a neglected condi¬ 
tion ; two patients sleeping together in one bed; bedding very dirty, 
and covered with fleas; some patients without shoes or stockings; hair 
neglected and filthy, &c. &c. All this is rather dismal reading. It is 
painful even to think of these poor creatures consigned to this death 
in life existence, victims of “ man’s inhumanity to man.” The writer 
can fully corroborate the strictures of the Inspectors from personal 
observation of the condition in which patients are often sent from 
workhouse to asylum, their skin and hair caked with filth, and 
swarming with vermin. 

The whole question of the condition of lunatics and idiots in work- 
houses is now being taken up by the general public and by the Press, a 
movement which will, we trust, be attended with good results. “ Evil 
is wrought by want of thought as well as want of heart,” and it is prob¬ 
able that only a comparatively few realise at all that there is such a 
class as the workhouse insane ; many, no doubt, do not even know of 
their existence ; those that do know have kept silent too long. 

The reports on private asylums are on the whole favourable, that on 
Hampstead Asylum (Dr. Eustace) especially so. With regard to the 
rest a perusal of the reports leaves the impression that they are not in a 
perfectly satisfactory condition; there is just something wanting to 
make them as comfortable and cheerful as such institutions ought to 
be at the present day. In Ireland, however, the straitened circum¬ 
stances of probably most of those who are obliged to seek the shelter 
of an asylum preclude the payment of anything like liberal fees. The 
proprietors of private asylums are consequently not in a position to 
make any large outlay on improvements, while luxurious appointments, 
such as are seen in English and Scotch asylums, except in very rare 
instances are absolutely out of the question. As long as the provision 
of accommodation for persons of small or moderate means is left in the 
hands of private persons who have to make their living in this way, 
much improvement can hardly be looked for. The Inspectors have 
made frequent reference to this subject, and in their latest report call 
attention to it. “ From year to year we revert to this subject in the 
hope that lunacy legislation dealing with the matter may be introduced, 
enabling the local authorities to erect in connection with, but entirely 
apart from the public asylums, accommodation for patients paying 
sufficient to defray the whole cost of their care and lodging.” It is 
more than probable that such institutions could not be altogether self- 
supporting. The average cost of maintenance of a pauper patient in 
the district asylums is about ^23. If asylums such as the Inspectors 


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suggest were provided we may assume that all patients who could pay 
over the pauper rate would be located in them. But the majority of 
them would probably pay sums varying from ^£25 to ^40 per annum, 
or perhaps or £60 in a few cases, and this scale of payment would 
hardly be sufficient to fully equip and carry on establishments provided 
with the comforts and conducted with the liberality now deemed 
necessary in order that the insane may have the best possible chance 
of recovery. Hence they will have to be, in part at least, supported 
by public money. It is not improbable that under the new Local 
Government Act, which will come into force in the course of this year, 
boards of governors will be empowered to make such additions to 
the district asylums as are suggested by the inspectors. 

In drawing attention 10 certain flaws and omissions in the Inspectors’ 
report, we have not the least desire to in any way detract from its 
general value, and we trust that any remarks of this kind which we have 
felt ourselves constrained to make will be accepted in the same spirit in 
which they are offered. We are anxious that these Annual Reports 
should give as accurate and comprehensive a sketch as possible both of 
the progress of lunacy and of Irish asylum work. We believe that if 
the Inspectors could see their way to adopt some of the suggestions 
offered, especially as regards the statistical tables, the value of their 
work would be considerably enhanced, the reports would have more of 
the quality of completeness which they do not now possess, and would in 
time become full and trustworthy works of reference for any student of 
the literature of lunacy in this country. 


The Origin and Growth of the Moral Instinct . By Alexander 

Sutherland, M.A. Two vols., demy 8vo, pp. 784. Longmans: 
London, New’ York, and Bombay. 1898. Price 2 8s. 


When we consider how intense is the mental activity of a certain 
kind that animates our brethren in the great continents of America and 
Australia, it is a matter for wonder that from these young, vigorous, 
active, energetic nations no great creative work has as yet proceeded. 
Among all the copious multitude of mechanical devices which America 
produces with such abundant fertility, there is no great mother-inven¬ 
tion which, like the steam engine, the hydraulic press, the printing- 
press, the spinning-jenny, the power loom, or the electric telegraph, is 
the fertile parent of a thousand others. Nor has any great epoch- 
making discovery yet been made in these young countries. No far 
reaching generalisation, no novel methods of research, does the world 
owe to their speculation or their ingenuity. Not only have they 
produced nothing to compare with the theories of gravitation and evolu¬ 
tion, the two most comprehensive generalisations to which the human 
intellect has yet attained, but, in particular sciences, no discovery of 
the first rank has yet been made by them. In vain we examine their 
achievements for any improvement in science comparable with, say, the 


differential calculus, with the undulatory theory of radiant forces, with 

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the correlation of forces, with the theory of chemical equivalence, with 
the spectroscope, with natural selection, with the localisation of cerebral 
functions, and so forth. It seems as if national youth, like individual 
youth, were a time of physical vigour and of mental assimilation, and 
that the earlier stages of a nation’s life were unfavourable to original 
discovery. 

If this speculation be true, the book whose name stands at the head 
of this article is evidence that the initial period in the life, at any rate 
of Australia, is passing away, and that that great country is entering 
upon a stage of development in which it will compete on equal terms 
with Europe for a place in the van of scientific progress. The 
publication of such a work would in any case be an important event in 
the history of mental and of biological science. Its publication by an 
Australian marks an epoch. It means that the era of really important 
discoveries by our kin beyond the sea has begun, and that henceforward 
we shall have to learn from them as well as to teach. 

Mr. Sutherland’s preface is a model of good taste. He ranks himself 
among the followers of Darwin, and speaks as if he were merely 
cultivating a field that Darwin had already reclaimed from the jungle. 
Non nobis sed tibi da gloria is his attitude. Such an attitude in an 
author is becoming, and it is doubtless true that but for Darwin’s work 
the book could not have been written ; but it is not in modesty alone 
that Mr. Sutherland shows himself a worthy disciple of his great master. 
His work is characterised throughout by patient, laborious research. 
To the support of every proposition he brings up his facts in battalions 
His propositions are. many of them, wholly new. Some of them are 
startling. Some of them are repellent. But to nearly all of them he 
at length wins our assent by the completeness of the evidence which he 
adduces in their favour. To the extraordinary difficulty of his task the 
present writer is well qualified to speak, since he has for a considerable 
time been at work upon the same lines as Mr. Sutherland, and was 
preparing a work, which will not now be wanted, pointing to similar 
conclusions. 


To give an outline of the book is for two reasons unnecessary. In 
the first place, Mr. Sutherland himself summarises the course of his 
arguments in what he calls a preliminary outline, and it would savour 
of presumption in a critic to attempt to improve upon what his author 
has done so well. In the second place, no student of mental science 
can afford to neglect the book. It is the most original and important 
work on mental science that has appeared for more than forty years. 
So far from examining over again the old problems, and wrangling on 
tickle points of niceness, such as whether the idea of space is innate or 
empirical, he imports into the subject a new method. He deals with 
the origin and growth of the moral instinct as a part of the great 
process of human evolution as conditioned by natural and sexual 
selection, and by the application of this new calculus he arrives at new 
conclusions. That the growth of mind in all its departments has 


proceeded in accordance with the law of evolution, has long been an 
accepted doctrine, although for many years Spencer’s Psychology was 
but the voice of one crying in the wilderness. But until Mr. Suther- 


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land, no one, not even Spencer himself, has applied to any great 
department of mind the working of natural selection and sexual selec¬ 
tion as set forth by Darwin, whose work on the limited subject of the 
expression of the emotions has been the sole excursus into this rich 
field of research. 

Not all of Mr. Sutherland’s propositions are established to conviction, 
but even those, such as the nature of the emotions, which appear the 
most open to objection, are admirably provocative of thought. In 
order to appreciate and admire his work it is not necessary, however, to 
agree with all his conclusions. It is enough to recognise how much he 
has given us of original thought, and with how much patient labour he 
has gathered the evidence in support of his novel propositions. 

The style is always pellucid, and, if it rarely rises to distinction, it 
preserves a general level of dignity and placid comeliness very suitable 
to the subject. It is so little marked by the inclusion of expressions 
peculiar to the colonial and American variations of our tongue, that 
English readers will not find their attention diverted by unfamiliar 
diction. 


Mental Affections of Children. By W. W. Ireland, M.D. Pp. 142. 

London : J. and A. Churchill. Edinburgh : J. Thin. 1898. 

This is practically a second edition of ‘ Idiocy and Imbecility,’ a 
work published by the author in 1877, but there are many additions. 
The present book represents his more matured views, and he has 
besides contrived to bring together scattered papers by various authors 
who have written on the subject of idiocy and imbecility. The chief 
additions are the pages on the Development of the Brain in Childhood, 
the Pathology of Genetous and Paralytic Idiocy, the chapters on 
Sclerotic and Syphilitic Idiocy, and that on the Insanity of Children. 
After two short chapters on the definition and statistics of idiocy and 
imbecility, he proceeds to give the causes, and rightly places neuro¬ 
pathic heredity at the head of the list. Under the heading of Genetous 
Idiocy he refers to the researches of Drs. Clouston and Eugene Talbot 
on deformities of the palate, and of the latter author on the degenerate 
ear. The pathological anatomy of this chapter has been added to, and 
some interesting remarks are made on the development of the infant’s 
brain, from which we learn that when a child is born he has only one 
third of the volume of his brain; the second third is acquired before 
twelve months are over, and the remaining third between that time and 
the twenty-first year. Reference is made to the operation of craniectomy 
in microcephalic idiocy, and the author deprecates its use, as he truly 
says it is founded upon incorrect pathology. With regard to epileptic 
imbecility, Dr. Ireland holds the opinion of the late Dr. W. A. F. 
Browne, and also held by the author of this review, that the subjects of 
epileptic imbecility, when successfully treated, are cases in which there 
is most decided improvement. The chapter on paralytic idiocy con¬ 
tains an account of porencephaly, and references are given to the most 

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166 

important papers on the subject. Sclerotic idiocy was first described 
by Bourneville fifteen years ago; it is a rare form, and the same remark 
applies to syphilitic idiocy. With regard to the former disease, the 
affection shows itself in the first few days, and generally before the 
expiration of twelve months after birth, and the frontal and occipital 
lobes are chiefly affected. Considerable space is given to the chapter 
on cretinism, and the thyroid treatment of sporadic cretinism is 
described, the evil results of over-doses being carefully pointed out. 
The chapter on insanity in children and insane idiots is much enlarged, 
compared with the former edition, and the fact that suicide in children 
is increasing in England and in almost all the Continental states is 
mentioned. Over-pressure in education is undoubtedly one of the 
chief causes, and in support of this we notice that in those countries 
where education is pushed on most strongly child suicide is found at its 
highest point. 

We have nothing but unqualified praise for this work. It contains 
the observations of a physician who has carefully studied the subject for 
many years, and who has embodied in the book all that is known about 
it at present; we highly recommend it as an indispensable manual, not 
only to medical men, but to all who have to do with the management of 
idiots and imbeciles. 


Reckerches cliniques et therapcutiqnes sur I'Epilepsie , PHysterie , et 
rIdiotic: Compte-rendu du service des etifants idiote , epileptiques y et 
Arrieres de BicUre pendant Pannee 1897. Par Bourneville 
(et huit collaborateurs). Vol. xviii, pp. 228. Paris: aux Bureaux 
du Progrh Medical; F&ix Alcan, 108 Boulevard St. Germain. 
Price 4 francs. 

In this annual publication we find not only a report of that portion 
of the Bicetre and its dependencies used for the treatment and training 
of the abnormal children above described, but also much clinical and 
pathological information of general medical interest. The classification 
of the inmates previously described seems year by year to be more 
minutely adapted to the various grades of defect, bodily and mental, 
of those under care; and we note with satisfaction the generous tribute 
accorded to the self-sacrificing women who devote themselves to the 
improvement of the ofttimes unpromising cases committed to their 
charge. Methods of teaching feeble children to walk, requiring much 
motherly patience, are successfully practised, and the habits are 
sedulously attended to. Some remarkable cases of improvement in 
these minor though practically very important matters are given in 
detail. The school arrangements, which the medical director keeps 
thoroughly in hand, seem well adapted to the feeble intellects under 
instruction ; and we note that special attention is given to the teaching 
from notes of vocal music. A band is also kept up from amongst the 
scholars, and has obtained a first prize at a contest at Charenton. 
“ Distractions ” are not overlooked, and various visits to theatres, 
concerts, and exhibitions are recorded. Vaccination or revaccination 

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is practised on all those admitted to the institution. Visitors are freely 
admitted to inspect the work on Saturday mornings ; numerous scientific 
inquirers have availed themselves of this privilege, and in October, 
1897, the Bicetre was honoured with a tour of inspection by the 
President of the French Republic, who addressed some cheering words 
to the staff. 

The pathological museum at the Bicetre is probably the most 
complete in the world of those connected with institutions for abnormal 
children, and increases in wealth of material year by year. Technical 
training continues to be given in eight different handicrafts, and the 
value of the work turned out by the printing office seems to be 
considerable. On the 1st January, 1897, there were 483 patients in 
residence at Bicetre; there were 63 admissions, 73 discharges, and 17 
deaths during the year. At the Fondation Valine there were 162 girls 
in residence, with 68 admissions, 27 discharges and transfers, and 19 
deaths. The latter seems a high comparative mortality, and we note 
that six deaths are attributed to pulmonary tubercle, and that the 
institution had been visited by measles and other infectious ailments. 
A somewhat amusing disquisition as to the fitness or unfitness for 
military service of a youth educated as an inmate of the Bicetre forms 
part of the report, it being maintained on the one side that to accept 
such a call would be an “ insult to the army,” and on the other that 
the sequestration of a conscript in an asylum is a scandal! In the 
result it would seem that decision as to the young man in question was 
deferred for a year. We happen to know of several ex-pupils of 
English training institutions for imbeciles who are serving with credit 
in our army, one of them having obtained corporal's stripes! 

A series of essays follow on a variety of subjects, such as the treat¬ 
ment of serous diarrhoea by salicylate of lime, epilepsy due to aneurisms, 
and a contribution to the study of false and true porencephaly. In the 
view of Boumeville and of Schwartz (who assisted him in this research) 
true porencephaly depends upon an arrest of development, whilst the 
condition described as pseudo-porencephaly is always the result of a 
pathological process. The latter may indeed be congenital, due to a 
malady of the foetus, but it may also be produced after birth, sometimes 
a long while after, as a consequence of encephalitis or haemorrhagic 
lesions, and subsequent atrophy. The distinctive characters of true 
porencephaly are the following:—(1) The cavity has the form of a funnel 
more or less regular, the base external, the apex towards the ventricle; 
its surface is smooth, and uniformly covered by the external pia mater. 
(2) The arrangement of the convolutions is characteristic, radiating from 
the bottom of the excavation, which may be said to be the point of 
convergence. (3) The orifice of communication is always regular, 
perfectly rounded, and forms what is designated the porus. (4) Around 
the excavation are found other anomalies pointing to arrest of develop¬ 
ment. The defects and the lesions in each variety are well shown in 
full-sized plates of the hemispheres of the brains taken from the 
respective patients, whose cases are fully described in the text. In the 
line which Bourneville draws between the two varieties he differs 
essentially from Heschl and other authorities. Epilepsy and the status 

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epilepticus is dealt with in other essays, and we note that capsules of 
“bromure de camphre ,, (Clin’s) and mixed bromides seem to be the 
remedies most in favour at the Bicetre. 


Les Maladies de rEsprit. Par le Dr. P. Max-Simon. Paris : Librairie, 
J. B. Bailliere et fils. Pp. 319. Price 3 fr. 50. 

Th is volume of the Bibliotheque scientifique contemporaine is a useful 
little work on mental diseases addressed to the general public. 

The first five chapters are devoted to a study of the alterations 
ob served in the mind of the insane, and deal successively with halluci- 
nations, illusions, and delusions; then with disorders of feelings, 
instincts, and conduct. Wherever possible the author has drawn from 
his own experience to illustrate his remarks, and he refers to some of 
his personal researches on the nature of hallucinations and the evolu¬ 
tion of delusions, &c. Max-Simon claims priority in emphasising the 
importance of the phenomenon of accidental images as a physiological 
proof of the nature of hallucinations. “ In an hallucination the sense is 
in a similar state to that which we find in the case of a real percep¬ 
tion.”' 

The chapter on delusional insanity, or rather on delusions and their 
variety, intermittence, alternation, &c., in the various forms of insanity 
is especially interesting; as is also that which the author devotes to a 
study of the delusional acts of the insane, and which includes a brief 
but pithy account of “tics.” This quality of pithiness is indeed a 
characteristic of the book as a whole; so that it can be recommended 
as an admirable introduction to the study of the insane, for it is also 
generally sound. 

The last two chapters deal with the causes of insanity and its treat¬ 
ment. 


Quel doit etre le Role du Patronage a regard des Alienes ? {Patronage 
Societies for the Insane ). Dr. Jules Morel. Vander Haeghen 
Gand, 1898, pp. 36. 


The above is the title of a pamphlet read as a paper by Dr. Morel, 
Mddecin-Directeur of the State Asylum at Mons, at the third Inter¬ 
national Congress for the consideration of the questions of the care of 
convicted criminals, abandoned children, and the insane, which was 
this year held at Antwerp. 

After commenting on the increasing and rapid development of public 
opinion regarding this question, and on the consequent activity of 
organised work in connection with it, Dr. Morel divides his subject into 
the following heads:—1. What can be done for the lunatic before his 
removal to an institution ? 2. During his period of seclusion ? 3. The 

assistance of their families deprived of their support. 4. What ought 


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to be done for a patient so far recovered that seclusion in an asylum is 
no longer necessary? 5. The development of public assistance. 6. 
The special education of children who have inherited tendencies to 
mental disease. 7. Provision of special asylums for children of defec- 
tive development and idiots. And 8. Means of diminishing the causes 
which might predispose to insanity. 

Dr. Morel considers that it is the duty of ail charitable organisations 
to extend their patronage to the insane and their families; that suitable 
members should be set apart for visiting reported cases, and as far as 
possible for treating those for whom enforced seclusion is deemed 
unnecessary. In the case where seclusion is absolutely inevitable, the 
patient ought to be guided and watched over to the very doors of the 
asylum, and his family protected, helped, and, if need be, supported 
during the period of absence of the bread-winner out of the funds of 
the society or societies undertaking such work. Thus, keeping each 
patient well in sight during his seclusion, the society must be ready to 
take him by the hand immediately on his release, whether entirely or 
partially recovered, and to continue its good offices until he is once 
more able to resume his place as bread-winner and responsible member 
of the social community. 

As necessary side issues of the main question, Dr. Morel advocates 
the establishment of special asylums for the development and education 
of those innocent victims of parental weaknesses who are yet capable of 
moral and mental training, and for the protection and care of such as 
are too hopelessly sunk in imbecility to need other than the usual 
bodily attention which their condition demands. 

In conclusion, Dr. Morel sketches out a plan for the formation, 
organisation, and administration of a society having for chief object the 
duties marked out above, impressing on his readers the growing neces¬ 
sity for such societies in view of the steadily increasing attention given 
throughout all the countries of Europe to mental disease and its 
victims. 


UAnnie psychologique . Publide par Alfred Binet. Paris: Schleicher 
frferes, 1898, pp. 849, price 15 fr. 


This is the fourth volume of Professor Binet’s useful year-book of 
psychology. As usual, half of the volume is devoted to the studies 
carried on in connection with the Sorbonne Laboratory of Physiological 
Psychology by M. Binet and his assistants, especially M. Vaschide. 
We have already pointed out that this is not a method to be commended, 
and this year there is more need than ever to repeat the observation. 
The original studies nearly all deal with a series of tests applied to a 
small number of French school children in order to ascertain their 
physical and mental characteristics. These papers are interesting and 
suggestive, and it is a striking proof of Professor Binet’s energy and 
enthusiasm that he should 1 ave such a large body of work to present as 
the result of a single year’s exertion, in addition to the labour involved 


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REVIEWS. 


[Jan., 


in editing this year-book. But it cannot be said that any very important 
or novel results emerge; as Professor Binet himself remarks, these 
studies are “ preliminary and tentative,” and it is therefore unreasonable 
that as much space should be devoted to them as to the summary of the 
psychological literature of the whole world during 1897. 

It is not possible to deal here with the twenty-two papers in which 
Binet and Vaschide record their experiments on school children. It 
will be sufficient to mention the subjects or the titles of the more im¬ 
portant studies: ‘Psychology in Primary Schools/ ‘Experiments on 
Muscular Force/with dynamometer and ergograph, and accompanied by 
interesting photographs of the expression of the children during effort; 
‘Studies on Reaction-time/ ‘On Respiration and Circulation, espe¬ 
cially during effort / ‘Conclusion of the Physical Tests/ with photographs 
of the strongest and the weakest boys: this is followed for the sake of 
comparison by a study of muscular force in the pupils at a normal 
school, and by further studies dealing with the normal school pupils in 
the same way as the younger boys had previously been dealt with; 
‘A Criticism of the Dynamometer / ‘A Criticism of the Ergograph/ 
‘The Physiology of Muscle in Experiments on Rapidity / ‘Respiratory 
Effort during Experiments with the Ergograph / ‘The Repair of Mus¬ 
cular Fatigue / experiments with a new ergograph. called the Spring 
Ergograph; ‘Reaction-time of the Heart, Vaso-motor Nerves, and 
Blood-pressure / ‘An Hypothesis on the Form of the Capillary Pulse/ 
‘The Consumption of Bread during the School Year* (showing maxima 
in April and October, due, the author believes, to the influence of holi¬ 
days just before these periods; an explanation which is, however, 
rendered more than doubtful by the fact, which Binet himself demon¬ 
strates, that even in prisons there is a similar rise in the consumption 
of bread in April and October); ‘ Influence of Prolonged Intellectual 
Work on Pulse-rate’ (slowing the heart and diminishing peripheral 
capillary circulation). Nearly all these studies are well illustrated by 
tracings and charts. There is, finally, a memoir by Bourdon summarising 
the results of recent studies on the visual perception of depth. 

It is unnecessary to refer to the summaries of the year’s literature (in 
which some forty pages are devoted to the pathological and abnormal), 
and to the bibliography, with its 2465 entries, beyond remarking that 
they are both as admirable as ever, and testify to the indefatigable 
energy of the editor, who has written the majority of the analytic 
summaries himself. 


Forensic Medicine and Toxicology. By J. Dixon Mann, M.D., 
F.R.C.P., Professor of Forensic Medicine and Toxicology in 
Owens College, Manchester, &c. Second edition, revised and 
enlarged. London : Charles Griffin and Co., 1898. Pp. 683. 
Price 2 ix. 


Professor Mann deals with his subject in three divisions—forensic 
medicine, insanity, and toxicology. In the part on forensic medicine 
there is included a concise description of the different forms of legal 


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171 

procedure in medico-legal cases; the sections on death from the 
electric current and on life assurance have been rewritten; and new 
sections have been added on the Obligation of Professional Secrecy, 
and on Sudden Death from Natural Causes. 

In the division on insanity a short description is given of the 
principal forms of insanity, and in the chapter on the medico-legal 
relations of insanity the questions of criminal responsibility of the 
insane, of drunkenness in relation to criminal responsibility, and of 
testamentary capacity are dealt with at length. 

The division on toxicology is particularly full, and contains new 
sections on blood poisons and on the post-mortem imbibition of poisons, 
as well as references to some poisons which have not been formerly 
included in any text-book on the subject. 

The treatment of the different subjects is very methodical, sufficiently 
full, concise, and clear, and the conclusions are stated in an impartial 
way. The illustrative cases quoted are aptly chosen, and the gradual 
development of recent views on the medico-legal relationships of 
insanity and drunkenness is well brought out, while the actual state of 
the law and its shortcomings in certain directions are clearly indicated. 
In cases where insanity is urged in bar of responsibility for crime. 
Professor Mann considers that the plea of insanity should be disposed 
of before the trial for the crime. The book is provided with a good 
index, and will prove very useful both for study and for reference. 


Guide to the Clinical Examination and Treatment of Sick Children . 

By John Thomson, M.D., F.R.C.P.Ed. Edinburgh : Clay, 1898. 

Crown 8vo, pp. 336. 

It is much better not to begin the study of disease in children until 
familiarity with its symptoms in later life has been acquired. In fact, 
young medical men have scanty opportunities of making themselves 
acquainted with the ailments of children till they commence practice, 
and then the majority of their patients are children. Not only their 
diseases are frequently not the same as those of adults, but the methods 
of examination are different. Treating sick children is more of an art 
and less of a science than with adults. Young children cannot assist 
by detailing their symptoms, and frequently resist examination. Here 
there is much room for tact and quick insight. Dr. Thomson begins 
with the action of development, and explains the anatomical and 
functional differences of the child from the adult; he then proceeds to 
the methods of examination and the meaning of symptoms. There 
are few medical practitioners, however skilful, who will not derive 
valuable hints from the directions which he gives and the precautions 
which he advises. The work also contains useful recommendations 
about the dietary' and nursery and hygiene of healthy children. His 
advice about the treatment of children in various diseases is clear and 
practical, and coming from one so thoroughly versed in the subject can 
be safely trusted for guidance. Dr. Thomson shows common sense as 

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REVIEWS. 


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well as learning, and while he generally accepts time-honoured maxims, 
he frequently explains and qualifies them in a useful way. In treatment 
he possesses the courage which is bom of skill and thorough-going 
diagnosis. He observes of the usual posological table giving the doses 
at various ages, that these must be modified by the size and strength of 
the children. He is not afraid to give doses somewhat larger than 
usual, and recommends bloodletting in cases “where from acute 
pulmonary or other disease the right side of the heart has become 
rapidly over-distended, and syncope threatens. Under these circum¬ 
stances the application of four to six leeches over the sternum may turn 
the scale in favour of recovery.” 

To the chapters on the nervous diseases of children we have nothing 
to object and little to add. The pages on infantile cerebral paralysis 
are especially good. In the chapter on mental deficiency in early 
infancy, Dr Thomson is much ahead of any treatise on children’s 
diseases which we have seen. He has made some original studies upon 
idiocy in young children, and his paper on this subject in the March 
number of the Scottish Medical and Surgical Journal is the most 
valuable contribution which has been made by a practising physician. 
One new feature in the book is the large number of plates, 52 in all; 
48 of these are zincographs taken from photographs from actual cases 
of disease, and illustrate the facies of the malady better than pages of 
wordy description. Dr. Thomson’s style is plain and clear, though 
sometimes his sentences are rather long and laboured. Altogether the 
book is of a most useful character, and sure to come into great request. 
Arrangements have been already made for a translation of the book 
into Spanish. 


On a Method of collecting the Pathological Statistics of the Insane Brain . 
By Francis O. Simpson, L.R.C.P., M.R.C.S., Pathologist and 
Assistant Medical Officer, West Riding Asylum, Wakefield. [ The 
Journal of Pathology and Bacteriology, May, 1898.] 


The essentials of Dr. Simpson’s scheme are as follows. Large sheets 
are employed for the purpose of recording—53$ inches long by 17$ 
inches deep, upon each of which 80 cases can be collected. Each sheet 
is ruled vertically in 233 columns, 10 to the inch; most of these have 
headings, there being a few blanks for possible extras. Between each 
subdivision of the examination scheme and its fellow a red line of 
demarcation is placed. The sheet is also ruled horizontally, one 
column for each case (80 columns); each fifth line is red (/. e. after 
each series of five cases). The autopsy over, the pathologist runs over 
his sheet, placing a stroke in the various columns, according to what he 
observes. The sheet full, it only remains to add up the columns at the 
bottom of the page, and to extract the percentages of the various lesions 
for the different forms of insanity. The scheme is comprehensive. 
Dr. Simpson hopes that those interested in insanity will adopt some¬ 
thing of a similar nature, in order that, by collaboration, a mass of 
useful information may be collected. Probably asylum pathologists 


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could not do better than adopt this scheme. We are, however, of 
opinion that general adhesion is much more likely to be given to & 
scheme sanctioned by a committee of competent pathologists appointed 
by an authoritative body to draw up such, than to any individual scheme 
emanating from a single asylum, however efficient. We cannot forget 
that individual efforts in this direction have failed before, though merit¬ 
ing, in our view, a better fate. 

The appointment of an authoritative committee to draw up a working 
scheme would in itself be indicative of a dawning desire for collective 
work in asylums, which, alike in clinical and pathological fields, is a 
consummation to be wished. 


Hysteria as a Psychosis.(}) By Dr. Donald Fraser. 


The Presidential Address to the Glasgow Pathological and Clinical 
Society w*as devoted to this interesting question. Dr. Fraser makes a 
very depreciatory statement as to the powers of observation of his fellow- 
countrymen by asserting his belief that “ we do not see many of the 
typical, and I may say developed forms of the disease, because we do 
not look for them.” 

This would seem to imply that these disorders were produced by the 
act of looking for them; this can scarcely be the case, for many 
physicians look sedulously without success, and would be greatly 
pleased to find marked examples of the disorder. 

The style of cases so commonly described by French writers would, 
however, force themselves on the observation of the most inattentive, 
and surely such observers as Buzzard, Gowers, and many others cannot 
be so classed. 

Speaking of their prominence in France, he uses the phrase “ grant¬ 
ing their over-development,” which seems to imply that their degree of 
development depends upon the attention of the physician, which would 
be a strong condemnation of the modes of treatment which produced 
such developmental results. 

Dr. Fraser quotes Sollier, who says “ there is not an hysterical disease 
in the cerebral mechanism which is hysterical; ” also the definition of 
Charcot and Marie in regard to its being a “peculiarly constituted 
mode of feeling and reaction; ” the view of Myers that “ hysteria is 
essentially characterised by an unreasonable auto-suggestion, ... and 
is a disease of the hypnoid stratum,” and speaks of the rdle of fixed 
ideas in the production and maintenance of the hysterical condition. 

The author alludes to the alterations of personality described by 
Binet, and says that the first of Binet’s propositions in regard to the 
development of them is the one we are concerned with as hysteria, viz. 
that it is to the disaggregation of the consciousness that many of its 
more striking phenomena are due. This, he says, is a “condition 
which permits the memories lost to the eye, though still subsisting in 
the subliminal consciousness, to assert themselves in bodily manifesta- 


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FRENCH RETROSPECT. 


[Jan., 


tions.” An important factor in this, he asserts, is the fixed idea, often 
depending on shock, &c. The memory, too, is essentially affected. 

The author quotes at length cases illustrative of these views, and 
concludes his instructive and suggestive paper by the statement that, 
while considering hysteria as a psychosis, he accepts Janet’s ('*) views as 
a working hypothesis. 

( l ) Glasgow Medical Journal, December, 1897. (*) fitat mental des hyst^riques; 

les stigmates mentaux. 


Part III.—Psychological Retrospect. 


FRENCH RETROSPECT. 


By Dr. Macevoy. 

The Seif-immured (voluntary entombment ).—Under this heading in 
Revue Scietitifiquc (1898, No. 10) M. Michel Delines resumes a study 
oi social psycho-pathology which Prof. Sikorski, of Kieff, has published 
in Questions de mcdecine ncvro-psychique concerning an epidemic of 
suicide which took place at Ternovo, in Southern Russia. Most of the 
details were obtained from the sole survivor of this tragedy, one Feodor 
Kovalev, who helped his co-religionists to bury themselves alive. 

The Kovalev family, belonging to the old Russian faith, owned some 
property at Ternovo, where they extended hospitality to their fellow- 
sectarians, so that in time a kind of convent (skit) was established, 
where men and women led an ascetic life. Two individuals were pre¬ 
dominant in the establishment, Mme. Kovalev, Feodor’s mother, and a 
certain woman called Vitalie,—the former a good, industrious, sweet 
woman ; the latter a spinster of thirty-five years, full of energy and 
decision. Vitalie very soon became the leading spirit of the convent; 
she administered the place and superintended everything (said mass, 
preached, laid down laws, &c.), although she made show of consulting 
Mother Kovalev. To a certain Pauline the younger, another inmate, 
Sikorski believes, however, must be assigned an important share in the 
elaboration of plans, and the psychological preparation for the terrible 
events which occurred at Ternovo, for Vitalie never decided upon any¬ 
thing before consulting her. Vitalie fasted, prayed, and read out from 
the old church works, but she knew very little concerning every-day 
occurrences as related in newspapers and modern works. Pauline, on 
the contrary, was more up-to-date, commented upon the events of the 
day, and stimulated the zeal of her companion. 

In the autumn of 1896 Vitalie and Pauline began to talk of persecu¬ 
tions which they foresaw against their sect; they told their companions 
that they were to be sent to Siberia or imprisoned. The habitual feel¬ 
ings of the inmates of the convent—exasperation, suspicion, and cause- 


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175 


less apprehensions—became more and more manifest in Vitalie, and she 
succeeded in deeply impressing the women and children of the Kovalev 
family. September and October appear to have been spent in a state 
of anxiety and fear by the members of the skit; all were expecting 
deportation or reclusion. They abandoned their ordinary occupations ; 
some provided themselves with a supply of warm clothing in case of 
exile ; others sold their worldly goods, preparing for death ; nights were 
spent in prayer, &c.; in short, life became intolerable to them, and 
when one of the young inmates exclaimed one day, “ Let us bury 
ourselves alive,” the suggestion was eagerly adopted as an alternative to 
the torture and mutilation which they anticipated in prison. 

The announcement of a general census throughout the Russian 
Empire precipitated matters, and may be called the exciting cause of 
this collective suicide, which Prof. Sikorski looks upon as an explosion 
of atavism; for the events which took place at Ternovo recall vividly 
the collective suicides by fire, water, and burial which were common in 
Russia at the end of the seventeenth century and during the eighteenth. 
The document which was handed over to the census-takers when they 
knocked at the door of the skit is identical with those which we find 
were written by the Sectarians of 1723 and 1736 prior to immuring 
themselves. 

Death by starvation was first entertained; but the fear that their 
children might survive them and be baptised in the orthodox faith led 
to the decision of burial. Vitalie was the prime mover in the prepara¬ 
tions for the entombment; she quoted scriptures in favour of this reso¬ 
lution, told the community that Antichrist had descended, that the end 
of the world was due in two or three days, &c. ; she even sent for her 
own sister and persuaded her to give a good example by taking the lead 
and burying herself first. 

Four groups were successively buried. The first group consisted of 
nine persons, and included Kovalev’s wife and two children, Vitalie’s 
sister, and Pauline’s father. The grave—four metres long, four metres in 
breadth, and equal in depth to the height of a man—was dug in a cave 
near the house of Fomine, at which the victims spent the night of 
December 23rd in prayer and singing hymns, &c. They proceeded to 
the tomb enshrouded, holding lighted tapers, and singing a funereal 
mass; the condition of religious ecstasy into which the victims had 
worked themselves seems to have taken away from the minds of Kovalev, 
Vitalie, and others who accompanied them all idea of the torture which 
they were about to undergo. Kovalev by command of Vitalie closed 
the grave after the last victim had descended. 

Among many of the details which were observed a few months later 
(April, 1897), when the grave was opened, it is interesting to note that 
no scratches or bruises were found on the bodies of the victims, such 
as are usually described in the case of persons buried alive; but an 
agonising death undoubtedly took place from asphyxia, probably in from 
one and a half to eight hours. 

Four days later a second group, consisting of six victims, were 
entombed ; among them was a hardened drunkard, Matei Soukhov, who 
seems to have been induced to join them while in a state of apathy 


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FRENCH RETROSPECT. 


[Jan., 


following upon a drinking bout. Kovalev, who again sealed the tomb, 
only at the last moment informed them of the fate of the first group. 

On the 5th of February’, 1897, Vitalie and six other persons were 
arrested by the police authorities for refusing to answer to the 
questions of the census officials ; but owing to their refusal to take food, 
they were allowed to return to the convent after five days—the convent 
being guarded. 

Shortly after this a third group, consisting of four women, one of 
whom was Kovalev’s sister, were buried. Kovalev buried them in a 
grave which he dug one kilometre away from his house; the victims 
were placed side by side, and he gradually covered them with earth, 
beginning with the legs, and finally flattening the earth over the bodies 
by treading upon it by command of Vitalie, who was the only other 
spectator of this gruesome tragedy. Death no doubt took place 
rapidly in this case; for when the bodies were unearthed later on, 
their eyes were found wide open, their tongues protruding, and the faces 
agonised. 

The last group, consisting of six persons, included Vitalie herself, 
Kovalev’s mother, Pauline the younger, and Dmitri, an idiot brother of 
Kovalev. Kovalev’s mother, who was strongly averse to suicide, was 
finally prompted to take the fatal step on hearing her idiot son Dmitri 
exclaim one day as if inspired, “Mother, why do you hesitate? Spit 
upon what you leave here below; but there, above, you will be happy.” 
Vitalie was also impressed by these words, but she seems to have joined 
the last group more from a feeling of fear that justice would later on 
fasten the responsibility of the previous suicides upon her, than from a 
conviction that her death was necessary to expiate her faults and 
qualify her for an eternal reward. 

Feodor Kovalev and his brother Dmitri dug the grave, and the former 
as on the other occasions sealed it, his last promise to Vitalie being 
that he would not long survive them. 

The last part of the article is taken up with an analysis of the 
character of Feodor Kovalev, who, whatever may have been his share 
in instigating these collective suicides, was the principal agent in 
carrying them out. Sikorski argues in detail, if unconvincingly, that he 
was a mere tool in the hands of Vitalie, but that his moral deliverance 
took place after her death. A careful examination of certain charac¬ 
teristics in the expression and facial stigmata of Kovalev leads him to 
conclude that there was a marked difference in their appearance just 
before his arrest (/. e at the time of the crime) and two months after. 

Under the influence of Vitalie, Kovalev would seem to have suffered 
from abolition of will, paralysis of energy and even feeling, although he 
was of fair development on the affective side. With time a feeling of 
remorse seems to penetrate into this callous nature, and he bemoans 
the absence of any one sensible person in the skit: “ Why was there no 
one there to enlighten us ? ” “ It is impossible,” says Sikorski, “ not to 

feel immense pity for this man, who now without ceasing questions those 
around him to clear up the mist which obscures his mind.” 

Such collective suicides as those of Temovo are not rare in the 
history of the Russian people, and Sapojnikov, in an interesting work, 


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FRENCH RETROSPECT. 


177 


mentions numerous examples which have occurred in the seventeenth, 
eighteenth, and nineteenth centuries. In most of them the instigators 
have taken no part in the suicides, but have been prime movers in the 
preparations. A process of psychological selection paves the way, so 
that communities of this kind in time come to consist (by gradual 
elimination of those who offer any resistance to morbid ideas) of 
degenerates, pessimists, psychically morbid individuals, &c., whom some 
enthusiast easily fires into the belief that suicide is a short road to 
eternal happiness. That collective suicide is almost confined to Russia 
is explained by the absence of treatment of the insane; one twentieth 
of them only, it appears, are under care in asylums, so it is easy to see 
how the remainder give a stamp of madness to the collective acts which 
occur during social crises. 

Unquestionably, among the sectarians of Temovo there were con¬ 
firmed lunatics; and besides the fear of the census, which was con¬ 
sidered to be the work of Antichrist, the inmates of the skit were told, 
among other things, by Vitalie that in dying they would found a place 
of pilgrimage rich in relics, where thousands would come, as at Tcher- 
nigov (where the miraculous relics of St. Theodosius had just been 
discovered), to worship. Kovalev, says Professor Sikorski, was so imbued 
with this idea, that when the remains of the immured were unearthed in 
his presence he manifested much exultation, and expected that miracles 
would follow. 

A study of this epidemic of suicides is in many respects of great 
interest, and is a further contribution to a subject which has received a 
good deal of attention of late years—the psychology of crowds. 

Criminal Lunatics .—Dr. Henri Colin, of Gaillon Asylum, urged at 
the meeting of the Soci&£ G£n£rale des Prisons the construction of a 
special State asylum for the treatment of criminal lunatics (see Revue de 
Psychiatric , 1898, No. 3). The generally received opinion at the 
present day is that criminal lunatics are a special class of individuals, 
differing from ordinary criminals and from the ordinary insane of our 
asylums, and therefore requiring special care. With regard to the 
difference which has been suggested between criminal lunatics and 
insane criminals, there appears to be no reason to apply different 
treatment to them. Prison treatment Colin does not consider a factor 
in the aetiology of insanity; insane criminals are either lunatics unrecog¬ 
nised, or individuals strongly predisposed to insanity by a morbid 
heredity. Three cases, among a number of others observed by the 
author, are given of insane criminals who were really unrecognised 
lunatics when sentenced. Motet has laid great stress on this. 

At present in France the treatment of criminal lunatics is unsatis¬ 
factory. Two cases may occur; either the individual is declared 
irresponsible during the trial, or the insanity manifests itself (or is 
recognised) after he is sentenced. In the first case the individual is 
discharged, or is sent to an ordinary asylum, whence he is soon 
discharged to begin over again. In the second case he cannot be kept 
in prison, and is sent to an ordinary asylum, or to the special quarter at 
Gaillon for insane criminals. The inmates here complete their term of 
imprisonment, at the end of which time, if still ill, they are sent to an 


XLV. 


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FRENCH RETROSPECT. 


Dan., 

asylum; if well, they are discharged, although, as Colin observes, there 
may be ten chances to one that there will be a recurrence. A few 
cases out of a number in his experience are quoted to show this. It is 
obvious that society is not well protected under this system. What is 
wanted is a special asylum, placed under the immediate control of the 
State, especially independent of the local influence of county councils, 
&c.; for the author mentions instances of ordinary lunatics who are 
left at large so as not to swell the rates of the district, and he per¬ 
tinently asks what will happen in the case of criminal ones. The 
construction of special quarters for these cases in the different asylums 
presents many obvious disadvantages. A central asylum, like our own 
Broadmoor, is therefore what Dr. Colin urges; and to prevent over¬ 
crowding he advises the adoption of the practice followed there,— 
dements, general paralytics, and incurable lunatics who have become 
harmless can be drafted on to ordinary asylums. Moreover conditional 
discharge, he believes, is a useful procedure. 

In conclusion, he also hopes to see Dr. Motet’s suggestion carried 
out—that there should be in all large prisons a special observation 
quarter for the reception of doubtful insane criminals. Only under 
these circumstances can proper expert reports be made; the prisoners 
simulating insanity can then be carefully examined, being submitted to 
skilled continuous observation. 

Atrophy of the Optic Nerve in relation to General Paralysis and 
Tabes. —Dr. M. Klippel {Revue de Psychiatries 1898, No. 4) endeavours 
to show that a consideration of the different reaction of the optic nerve 
in the two diseases tabes and general paralysis throws light on their 
different pathogeny. 

Grey degeneration or grey atrophy of the optic nerve leading ta 
blindness is fairly frequent in tabes, but absent in general paralysis. 
Why this difference? The explanation is that in tabes the more 
peripheral neurons are affected, in general paralysis the more central 
ones. 

If occasionally the central neurons are affected in tabes {e.g. tabetic 
dementia) it is only secondarily, late in the disease, and with difficulty ; 
and in the same way it is infrequent to find general paralysis reacting 
upon the peripheral neurons. 

If we take the retina, we find that it contains certain nerve-cells, with 
prolongations constituting the optic teleneuron. On the one hand 
these protoplasmic prolongations are related to cells which transmit to 
them the luminous impressions. The impression reaches the centre of 
the cell, hence it travels in the cylindrical prolongation, where fresh 
neurons intervene. The luminous impression is carried by them to the 
ganglia at the base of the brain, where it is again taken up by a third 
kind of neuron in contact with those of the periphery. 

In tabes the two optic teleneurons are affected. What do these 
peripheral neurons of vision represent in the domain of general sensa¬ 
tion ? Certain cells of the retina are the homologues of the cells of the 
spinal ganglia; the retina is in part an intervertebral ganglion projected 
to the periphery. So that grey degeneration of the retina is nothing 
else but grey degeneration of the peripheral teleneurons. This is not 


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FRENCH RETROSPECT. 


179 


merely an enticing hypothesis; for let us recall in this connection that 
in some animals the spinal ganglia, placed at the level of the external 
tegument, are in the same position as the retina in man : moreover in 
man, too, the centre of the gustatory teleneuron is already far apart 
from the bulbar origin of the glosso-pharyngeal nerve; and that, still 
more important, the olfactory teleneuron is none other than the olfac¬ 
tory cell seated in the pituitary membrane, the olfactory nerve itself 
representing nothing more than a posterior spinal nerve-root. Weil, 
tabes is precisely a disease which affects all or part of the system of the 
sensory teleneurons, both those of general sensation and those of 
special sensation. The localisation of tabes is, therefore, in the peri¬ 
pheral neurons. 

Now if we consider general paralysis, we find that it is the central 
neurons which are affected; these occupy in the nerve-centres and in 
the spinal cord different sites from those of the teleneurons which are 
prolonged into them. It is for this reason that the posterior roots, and 
especially that which the retinal system represents (an integral part of 
the neurons in which tabes is localised), are not affected or only very 
slightly by general paralysis ; in any case that they can only be affected 
by reason of what Klippel calls “ the degeneration of transmission,” and 
not through a primary and intense localisation in them. 

To resume, the presence of grey degeneration of the optic nerve 
leading to blindness in tabes, and its absence in general paralysis, seem 
to enable us to establish the respective distribution of the lesions in 
these two diseases, if we take care to deduce the general considerations 
which are related thereto. Probably no neuron of sensation is more 
strikingly affected in the one disease (tabes); none more clearly spared 
in the other. 

A Case of Juvenile General Paralysis beginning in the Spinal Cord .— 
Professor Joffroy d propos of a case of juvenile general paralysis, makes 
some important remarks on this affection ( s . Revue de Psychiatries 1898, 
No. 6). Female, aet. 23, was shown to his class at St. Anne Asylum, 
after having been ill two years, in a helpless condition, unable to walk 
or stand up, with violent tremors, marked affection of speech, inequality 
of pupils and Argyll Robertson phenomenon, demented, and having 
lost control over bladder and rectum. In addition there was marked 
general anaesthesia and slow reflexes, suggesting the idea of a medullary 
lesion. 

In this connection he recalls a case of a youth aet. 19 years, who, after 
being ill on and off for four years, went under Charcot at the Salp&tri&re 
with paraplegia, leading to a diagnosis of “ organic lesion of the spinal 
cord.” Undtr a treatment with ergot and the actual cautery the para¬ 
plegia disappeared. Later on there appeared anaesthesia of the face and 
arms, and siftiophobia, which suggested hysteria. Whereupon there 
rapidly appeared weakness of legs, emaciation, affection of speech, 
tremors of lips, unequal and inactive pupils, wet and dirty habits, &c., 
and early death, with post-mortem evidences of general paralysis. 
“ These famous cases of tabes ending in general paralysis,” says Joffroy, 
11 are really cases of general paralysis beginning with lesions of the spinal 
cord,” 1. e. pathologically and often clinically distinct from true tabes. 


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FRENCH RETROSPECT. 


[Jan., 


Looking over the records of twenty-two cases of juvenile general 
paralysis (Clousten, Turnbull, R£gis, Wiglesworth, Ballet, Charcot and 
Dutil, Legrain, &c.), after reviewing some of the important clinical 
aspects of these cases, predominance of physical signs and of emacia¬ 
tion, rarity of megalomania, disorders of sensation, &c., the aetiology, 
especially to Joffroy, is a question of great interest Puberty appears to 
be the common period of invasion (average age of onset fifteen and a 
half years for males, fourteen and a half for females) in these juvenile 
cases, but the most potent factor is heredity . In seventeen out of the 
twenty-two cases referred to above, one finds marked nervous disorder 
in the family (insanity, nervous diseases, or neuroses). Joffroy exa¬ 
mines the much debated rdle which alcohol and syphilis in the 
generators are said to play in the causation of this disease; he much 
-doubts whether the child of a syphilitic parent is necessarily tainted, and 
shows how important it is to discriminate in talking of congenital or in¬ 
herited syphilis. Alcohol, on the other hand, he believes to be a 
powerful aetiological factor in this disease. 

The Toxicity of Sweat in Epileptics and Melancholiacs .—Mavrojannis 
has made observations on the character of the sweat in epileptics and 
melancholiacs, among patients under the h care of Dr. Toulouse, which do 
not at all agree with the conclusions of Cabitto of Geneva ( Revue de 
Psychiatries 1898, No. 7). 

In the case of epileptics the patients were females, and the urine first 
passed after each attack was carefully examined as well as the sweat. 
Like other observers, he finds that the toxicity of the urine is nearly 
always below the normal. 

Experiment 1.—L—, 32 years. 20 c.c. of sweat collected half an hour 
after a strong attack. Injected into the veins of a rabbit: slight depres¬ 
sion and some aching of the back; no symptoms one hour later. 

Experiment 2.—J—, 27 years. 45 c.c. of sweat collected in forty-five 
minutes after an attack. Injection into a rabbit causes temporary 
depression and a few movements of forced extension of the spine, &c. 

The conclusions from six similar experiments are that the sweat of 
epileptics immediately after fits is not highly toxic; Cabitto says it is; 
but injected in rabbits it produces, as a characteristic symptom, move¬ 
ments of forced extension of the spine not observed in the case of 
normal sweat. 

With regard to melancholiacs, while one is prepared a priori to find 
that all the excretions are more toxic than normally, as has been often 
proved in the case of the urine, Mavrojannis concludes from his obser¬ 
vations that such is not the case with the sweat. 

The Endeavour to Live and the Theory of Final Causes .—Professor 
Charles Richet, in Revue Scientifiques 1898, No. 1, returns again to the 
question of final causes, and in an interesting article endeavours to prove 
that in the case of living beings, in addition to the existence of the law 
of the struggle for life, we must admit also that of the endeavour to live 
as a final cause. 

It is easy, he says, to turn the theory of final causes into ridi¬ 
cule. The nose, said Voltaire, is made to carry spectacles, and 
unquestionably many of the dicta of “ finalists ” have justly been the 


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FRENCH RETROSPECT. 


I8l 


source of much amusement. Galen was never at a loss to find a cause 
for all that he observed in anatomy; “ If the air were denser, we should 
be unable to walk,” said F^nelon, &c.; small wonder, then, that even 
great minds have considered it a superstition unworthy of being con¬ 
sidered in any scientific philosophy. But while it must be admitted that 
our ignorance of the world is profound, and our intellect singularly im¬ 
perfect, so that we can never grasp the why of the natural laws which 
govern matter, or the cause of the world in its immensity, yet it may 
be possible for us to draw conclusions concerning certain of its 
parts. 

We cannot, for example, resist saying that the eye is constructed to 
see, the heart to drive the blood, &c. Physiology and anatomy show 
us an extraordinary complexity in the play of parts of our frame. The 
physiologist must conclude that the reflex cough excited by the inhala¬ 
tion of a foreign body into the larynx has a final cause—the expulsion 
of the foreign body. And so impressed are we with the truth that the 
various parts of the animal mechanism have their use, that we obsti¬ 
nately try to discover the function of each organ: because we ignore 
the true function of the spleen, we never think of concluding that 
the spleen is useless; but we go on seeking, convinced from our 
general experience in other directions that sooner or later we shall 
discover it. Nature has not made useless organs ; everything has a 
goal. 

Zoologists are also finalists; books upon books have been published 
upon the various means of defence among animals; but what is the 
dominant idea that arises in the mind when we discover that the 
octopus emits an ink-like fluid when surprised by an enemy; or that 
the crab parts with a section of its claw when held by it ? Simply that 
the various functions of defence have for their end the safeguard of the 
organism attacked. 

But in the search for final causes detail alone is not sufficient. Have 
living beings as a whole great general functions adapted to an end ? 
Take that of reproduction. If we do not accept the hypothesis that 
Nature intends the perpetuity of the species, and that she has taken a 
host of ways of insuring it, we understand nothing; but all is clear to 
us if we admit that Nature has an aim, which is to insure life to the 
species. 

Fear, vertigo, pain, &c., Prof. Richet shows are useful and necessary 
to the life of the individual (see in this connection “ Biological Study of 
Pain,” Revue Scientifique % August 22nd, 1896, abstracted in Journal of 
Mental Science , vol. xliii, p. 408), so that the feelings and sensations of 
living beings are, like the structure and functions of their organs, 
related to the conservation of the individual and the conservation of 
the species. 

A general conclusion forces itself upon the mind that living beings 
are organised to live, a conclusion which is admirably in accordance 
with the hypothesis of natural selection. 

To establish the truth that beings tend to live, that the endeavour to 
live is a final cause, is possible, but we cannot go beyond and say why 
there is life. To eliminate everything hypothetical Richet suggests 


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[Jan., 


that the law should be thus stated: “ Everything occurs as if Nature 
desired life ; ” and this proposition he considers unassailable. 

Treatment of Insanity by Rest in Bed. —Dr. Keraval (Le Progrh 
Medical , 1898, No. 25) gives an interesting review of the progress which 
the question of the treatment of the insane by rest in bed has made 
during the last few years in various countries. 

It is interesting to note the variability in the views held by different 
physicians as to the kind of cases which seem to be benefited by this 
treatment, and the length of time during which recent cases should be 
kept in bed. 

The evolution of this mode of treatment extends practically over the 
last fifteen years, and it is quite evident that for a due appreciation of 
its potency for good, account must be taken of the circumstances under 
which it is carried out and has been carried out in various asylums. 
The construction of the asylum and the means at its disposal (number 
of attendants, mode of supervision, &c.) are most important factors in 
this connection. It is obvious that one cannot compare the results of 
treatment of recent cases of melancholia kept in a common dormitory 
within close access of other wards with the results of treatment of 
similar cases kept in bed in well-isolated separate rooms. 

In the present state of our knowledge, based on the observations of 
German, French, English, Russian, &c , alienists, one can only say that 
this mode of treatment is on its trial. It is difficult to conclude as yet 
that even one certain class of mental cases is likely to improve under it, 
and unfortunately there stands strikingly in the way of extensive trials 
of the method the question of expense. 

The Present Increase of Nervous Disorders. —The Revue Scientifique , 
(1898, No. 14) contains an address given by Erb to the University of 
Heidelberg on the increasing prevalence of nervous disorders. After 
enumerating the numerous factors which especially during the present 
century have contributed to upset the nervous system of man (wars, 
revolutions, discoveries, &c., political and social events of all kinds), 
Erb tries to define that vague condition which we call nervousness , a 
kind of transition between health and disease, and very often the most 
propitious soil for the development of the latter. To the idea of 
nervousness we connect all that denotes an acute excitability of the 
nervous system; precipitation and a certain disturbance in movements 
and work, excessive sensitiveness, tendency to fright, irritability accom¬ 
panied with depression, an enfeebled resistance to the small disappoint¬ 
ments of life (“to the malignancy of the object” [Vischer]), a change¬ 
able disposition, disturbed sleep, depression after each laborious effort, 
excitability of the heart and the vascular system, &c. While he believes 
that there is now-a-days a progressive increase in organic diseases of 
the nervous system, general paralysis, tabes, apoplexy, myelitis, &c. ; 
and an enfeebled capacity of resistance against the noxious elements 
which especially affect the nervous system (poisons such as alcohol, 
lead, arsenic; infections such as diphtheria, influenza, syphilis, &c., 
traumatism, &c. &c.), it is especially to the increase of functional 
neuroses that he draws attention,—an increase particularly convincing 
as regards hysteria, hypochondriasis, and neurasthenia. 


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183 


Neurasthenia is predominant to-day; it is the most frequent and the 
most important of the neuroses, and when one speaks of the great 
frequency of “ nervousness ” as a special disease, it is neurasthenia one 
has in one’s mind. Reviewing the history of this disease in the past, 
with the probable extent of its incidence, Erb believes that the 
experience of medical men during the last ten years, say, is unanimous 
that it is on the increase, and greatly so. 

What are the causes of this increase ? This is the next point which 
Erb inquires into, and his formidable list arranged under eight 
headings is a severe indictment against the age in which we live. The 
conditions of life at the present day all predispose to this affection. 

With regard to the future, he sees rays of hope. The hygiene of the 
nervous system is still in its infancy, but it will grow; in dealing with 
the prophylaxis of nervousness, some of the evil effects associated with 
the progress of civilisation we cannot hope to eliminate; but in the 
direction of the physical and intellectual care of children in their early 
age, and later when at school, much improvement will be made. (An 
“ association for the hygienic education of youth ” has just been started 
in Berlin.) With the growth of knowledge, professional hygiene will be 
more carefully studied. Society itself can do much, and it is especially 
gratifying to find that the fight against alcoholism, the adoption of 
Sunday as a day of rest, the limitation of hours of labour, &c., are 
becoming more wide-spread. That a good deal more can be easily 
done, a glance at some practical suggestions made by Erb in this 
address will show. 

Embodying as it does the opinions and suggestions of an eminent 
authority on nervous diseases, this is an address which should be 
widely read. 

Amceboidism of Nerve-cells; Histological Theory of Sleep; Nervi 
Nervorum .—In Revue Scientifique , 1898, No. n, is a reprint of the 
lecture delivered by Professor Mathias-Duval at the close of his course 
on histology at the Acaddmie de M^decine. When, with the researches 
of Cajal, Kolliker, Retzius, &c., we were led to adopt the view of con¬ 
tiguity of the ramifications of the neurons, as against the view of 
continuity entertained by Gerlach, it was natural to inquire whether 
these protoplasmic ramifications are susceptible of approaching to, or 
receding from, one another in virtue of their contractile property. This 
is essentially the hypothesis of nervous amoeboidism. Already in 1890 
Rabl-Riickhardt suggested that these movements might account for 
differences in the functional states of nervous arese, and in 1894 we 
find Lupine suggesting that possibly sleep might be due to the retraction 
of cellular prolongations leading to their isolation from one another. 
In 1895 Mathias Duval himself, in a communication to the Soci£t£ de 
Biologie, insists on the phenomena presented by olfactory cells, which 
are now generally admitted to be nerve-cells, the peripheral prolonga¬ 
tion of which (the homologue of the protoplasmic ramifications of the 
neuron) is capable of movement—“We may therefore conceive that the 
imagination, the memory, the association of ideas, become more active 
under the influence of certain agents (tea, coffee) whose function would 
be to excite amoeboid movements in the contiguous extremities of 

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.FRENCH RETROSPECT. 


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184 

nerve-cells, causing the ramifications to approach each other, and 
facilitating the passage of impulses.” This communication stimulated 
research, so that to-day the anatomical proof of this hypothesis is forth¬ 
coming. The theses of two of Mathias-DuvaPs pupils, Messrs. Pupin 
and Deyber, are of much importance in this connection, and still more 
recently Professor Mathias Duval draws attention to the convincing 
observations of Manou&ian carried on in his own laboratory. 

A comparative study of sleep with the waking state leads to interesting 
speculations, to which may easily be adapted the theory of nervous 
amoeboidism; in sleep some interruption to the passage of nervous 
stimuli occurs at the level of articulation of the peripheral sensory 
neuron with the central sensory neuron, and at the level of articulation 
of the latter with the psychic neuron (pyramidal cells). To less 
intimate contiguity of cells this interruption must be due. How does 
this arise ? We can only suppose that the cellular ramifications 
become further apart by a slight retraction towards the body of the 
cell, or by undergoing some lateral displacement. Experimental data 
favour the first view; Manou&ian’s observations on tired animals show 
that the fatigue of nervous elements brings about the isolation, the 
retraction of cellular prolongations. 

The earliest anatomical researches upon the amoeboid movements of 
cells were carried on upon cells very nearly related to nervous cells; 
retinal cells, olfactory cells, <fcc., and the discovery of the existence of 
movements in these affords what Mathias - Duval calls “proofs by 
analogy ” of the existence of similar movements in true nerve-cells. 

Pergen’s recent experiments upon fishes {Leuciscus rutilus) confirm 
those of Kiihne, Angelucci, &c. A comparison of sections of the 
retina from the eyes of one group of fishes kept in complete darkness 
for forty-eight hours, with those from another group exposed to light, is 
most conclusive. In the former we find retracted pigment-cells, with 
short, sparsely pigmented pseudopoda ; in the latter the pseudopoda 
are long, project deeply between the cells of Jacob’s membrane, and 
are charged with pigment. 

A study of the olfactory cells, which are now looked upon as true 
neurons—bipolar cells, homologous and similar to the bipolar cells of 
spinal ganglia—also confirms the theory of nervous amoeboidism; for 
Ranvier and others have well shown that there are characteristic 
movements, different to those of ordinary vibratory cilia, to be seen in 
the living olfactory cilia of frogs. 

Direct observations on the pyramidal cells of animals are for the 
first time demonstrative of the “amoeboidism” theory in the experi¬ 
ments of Demoor and of Stefanowska; Demoor observes a moniliform 
appearance in the prolongation of cells in animals morphinised, and 
their retraction towards the body of the cell. Stefanowska’s observa¬ 
tions extend especially to the morphology of the spines or spinous 
processes of the dendrites (“ Swedish ladder ” appearance, so-called 
happily by Demoor), for which she suggests the appellation of “pyriform 
appendices,” owing to their characteristic form. It is, according to 
her, through the medium of these pyriform appendices that is effected 
the contact between the prolongations of cerebral neurons, and as they 

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FRENCH RETROSPECT. 


I»S 


may according to circumstances project from, or retract into, the den¬ 
drites, we find an anatomical proof of the existence of pseudopoda 
foreseen in the ingenious theories of Mathias-Duval, Lupine, and Rabl- 
Riickhardt. 

The more recent researches of Manoudlian entirely confirm these 
observations. It might have been objected to the experiments of 
Demoor and others that the employment of morphia, of electricity, &c., 
introduced sources of error. Manoudlian brings about fatigue in 
mice by persistent stimulation (teasing them, &c.), and compares their 
cerebral cells with those of ordinary mice. The rapid method of Golgi- 
Cajal is that which he generally uses for his preparations, and the 
pyramidal cells and the mitral cells of the olfactory bulb are especially 
studied. Among other conclusions he finds that “the spines of the 
ramifications of the dendrites (in pyramidal cells) disappear in the case 
of the fatigued mouse, while spherical thickenings occur here and 
there in their length, more especially towards their extremities,”—a 
confirmation of Stefanowska's observations. 

The existence of amoeboid movements in nerve-cells being demon¬ 
strated, a question which has puzzled even the most confirmed 
supporters of the theory is to explain why and how the arborisations 
can be incited to approach or separate from one another. Cajal 
suggests the existence of amceboidism in the neuroglia cells ; Mathias- 
Duval and Manou&ian suggest the theory of nervi nervorum, i.e. 
centrifugal nerve-fibres presiding over the protoplasmic movements of 
the ramifications of nerve-cells; a theory analogous to that of vaso¬ 
dilatation and vaso-constriction, &c. The anatomical proof of this 
theory is borne out by the observations of Ramon y Cajal in the case 
of the retina, and by those of Manou&ian for the olfactory bulb. 
Manou&ian's preparations, says our author, “afford an irrefutable 
demonstration of the existence of the centrifugal nervous fibres, and of 
their termination at the level of articulation of the cylindraxil pro¬ 
longations of the peripheral olfactory neurons with the protoplasmic 
prolongations of the central olfactory neurons.” For these nervous 
fibres presiding over the amoeboid activity of the neurons, the name 
nervi nervorum is proposed. Sappey gave this name to the> nervous 
ramifications which he discovered in the interfascicular connective 
tissue of nerve-trunks; but Sappey's nervi nervorum are in reality vaso¬ 
motor nerves to the vessels of these nerve-trunks. Mathias-Duval’s 
nervi nervorum, on the contrary, are related to the nerve-cell in the 
same way as the motor plates are to the muscle-cells. In conclusion, 
Mathias-Duval says that whatever may be the ultimate fate of this 
theory, the communications of Cajal and Soukhanoff may perhaps be 
said to have first embodied it; “ but of quite secondary importance it is 
for him to see his own name attached to the emission of a new idea; 
the essential is that the idea should spread and succeed.” 

Amceboidism of Nerve-cells .—The ingenious and suggestive views 
concerning the amoeboid movements of nerve-cells to which we have 
referred in an abstract of Professor Mathias - Duval's lecture, have 
recently been confirmed in the case of the spinal cord by Robert Odier 
of Geneva (vide Revue Scientifique , 1898, No. 22). The researches are 


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FRENCH RETROSPECT. 


[Jan., 


186 


confined to a monograph published at Geneva (Georg et Cie.) “ Mouve- 
ments de la cellule nerveuse de la moelle £pini6re.” Sections of the 
spinal cord from active animals and from animals at rest when compared 
with each other exhibit certain important differences in the appearance 
of the cells; so that their extremities are extended at rest, and retracted 
during activity. This retraction of pseudopoda is well seen when the 
spinal cord is artificially stimulated. It would appear that with an elec¬ 
tric stimulus, the retraction of dendrites takes place in the direction of 
the current, and only the prolongations parallel to it are affected. 
Odier finds, like other observers, that this retraction may affect the body 
of the cell and even the nucleus later on. With prolonged stimulation 
important alterations take place in the chromophile part of the cell; 
instead of the regular distribution observed while the cell is at rest, we 
find a disposition in asymmetrical masses; the behaviour to staining 
varies. With an exhausted spinal cord, one notices successively, retrac¬ 
tion of cellular prolongations, reduction in the chromophile elements, re¬ 
traction of the body of the cell, then of the nucleus, and finally of the nu¬ 
cleolus. In the nucleus itself the chromatic elements are the most sen¬ 
sitive, as has been generally held. These observations seem to show 
that anatomical and chemical alterations in the nerve-cells arise from 
fatigue, although it is not clear that some of these changes are not patho¬ 
logical. 

Case of Acromegaly ivith Dementia. —Professor Joffroy (Le Progrls 
Medical , 1898, No. 9) gives the notes of a case of acromegaly, upon which 
he bases an interesting clinical lecture, occurring in a woman who had been 
under his care for some years. The early manifestations of the disease 
were noticed at the age of fifty-three or fifty-four years, and when shown 
to his pupils on her admission at Sainte-Anne four years later, she was 
a typical case of the condition : characteristic physiognomy, with large 
nose, prominent superciliary ridges, maxillary prognathism, enlarged 
tongue and lower lip, and there was marked affection of the hands, 
feet, clavicles, &c. Her height was normal and stationary, as is usually 
observed in cases occurring after the menopause, in contra-distinction to 
the marked increase in height, amounting frequently to gigantism, 
which occurs in younger patients, i. e. during the reproductive period. 

In addition to the classical symptoms of acromegaly, Joffroy’s case 
was complicated with cardiac disease (aortic obstruction and incom¬ 
petence, with hypertrophied left ventricle). 

The psychical symptoms in the case were more marked than usual, 
which led to her admission to the asylum ; her memory was considerably 
diminished; she could not remember the date of the month or the day 
of the week, and she forgot from one moment to the other what was 
said to her or what she was obliged to do in her work, so that she 
could do no shopping or prepare her food. She was indifferent, 
apathetic, and often helpless. 

The author discusses the pathogeny of acromegaly, reviews the 
various theories brought forward, draws attention to its analogy with 
Graves’s disease, and inclines to P. Marie’s view that acromegaly is 
due to a lesion of the pituitary body. Gigantism he considers to be 
the same disease as acromegaly, only occurring before adult life, that is 


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FRENCH RETROSPECT. 


187 


during the period of growth. Treatment of various kinds and with 
various drugs was of no avail in his case, and Joffroy believes that so 
far we are not in possession of any useful remedy for acromegaly. 

Epilepsy consecutive to Typhoid Fever .—The relation of nervous 
diseases to the infectious diseases in general and to typhoid in par¬ 
ticular is an important one, and the notes of this case reported by 
Bourneville and Dardel {Le Progrh Medical\ 1898, No. 12) are of 
interest in this connection. A child of good family history was bright 
and intelligent up to the age of three years, when he was seized with a 
sharp attack of typhoid fever (which at the same time carried off his 
mother, one of his brothers, and one of his sisters), with nervous com¬ 
plications. Two months after this illness, which left him very weak, 
he was suddenly attacked with epileptic convulsions, and became hence¬ 
forth a confirmed epileptic subject, at first to weekly attacks and then 
to more frequent ones. His intellectual faculties became more and 
more dimmed, especially between the age of nine and eleven years, 
when he was admitted as an idiot under the care of Dr. Bourneville. 
Progressive bodily and mental enfeeblement occurred, and he finally 
died a year later from a recurrent attack of enteritis not due to any 
macroscopic lesion of the bowel, possibly nervous in origin. At the 
post-mortem examination, details of which are fully given, the most 
marked features were an arrest of development of the frontal lobes, 
sclerosis of the occipital lobes, and a remarkable asymmetry of the 
cerebral convolutions on both the convex and internal aspects of the 
two cerebral hemispheres. (Figures of these are shown.) 

Chronic Alcoholism .—In Revue Scientifique (1898, No. 3) Professor 
Joffroy^ lecture delivered at the Sainte-Anne Asylum on the etiology 
of alcoholism, and the result of certain experimental researches on the 
action of alcohol, will be found. It is important to remember that 
chronic alcoholism in nearly all its symptoms differs considerably from 
acute alcoholism, and that what we call alcoholic intoxication is a 
complex condition arising from the introduction into the blood of a very 
variable toxic mixture in which ethyl alcohol holds the first place. 
Moreover, a most variable factor in the question is the individuality 
upon which the various alcoholic beverages act, modified, of course, by 
inherited or acquired tendencies ; hence the differing preponderance in 
various cases of lesions of the stomach, liver, lungs, kidneys, &c. 
These preliminary considerations, among others, suffice to show the 
colossal nature of a truly scientific study of alcoholism. 

Professor Joffroy here communicates the results of one method of 
throwing light on this question—the experimental; ethyl alcohol, 
methyl alcohol, aldehyde and furfurol were the four ingredients of 
certain alcoholic beverages first selected, and they were administered 
daily to dogs over certain periods of time—not, one might add, without 
difficulty, for several subjects of these experiments absolutely refused 
their alcoholised food after a short while. With certain variations 
dependent upon the individuality of the animal experimented upon, the 
results support, more or less, those of other observers; ethyl alcohol is 
toxic, it determines modifications of character, paralytic phenomena, 
lesions of the stomach and bowel, of the liver, and occasionally of the 


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188 


FRENCH RETROSPECT. 


[Jan., 


kidneys; finally, even with a small dose of alcohol, death may supervene 
fairly quickly. That the presence of salts of potash, as in wine, may 
aggravate the toxic effects of this beverage, as the experiments of 
Lancereaux seem to show, is not denied. Methyl alcohol, according to 
Joffroy’s experiments, acts much in the same way as ethyl alcohol. 

In the case of aldehyde , lesions of the digestive tract, and profound 
modifications of the urinary function, speedily fatal, were especially 
marked. 

The difference between chronic and acute intoxication is well 
exemplified in the case of furfurol; while in the latter it is very active, 
it appears to produce very little effect in chronic intoxication. In a 
dog to whom it was given in fairly strong doses daily for twenty months, 
the only result was some appearance of senility; no other psychical or 
physical disturbance was noted. 

Entertainments in the Treatment of the Insane .—Dr. Naecke, of 
Hubertusburg Asylum ( Revue de Psychiatrie , 1897, No. 10), is sceptical 
of the curative power of music, theatrical performances, &c., in insanity, 
but speaks strongly in favour of entertainments and diversions of all 
kinds as aids to treatment in the majority of cases. It is important, 
however, to exercise discrimination ; the medical superintendent should 
be a psychologist of the different classes of society and discover that 
form of diversion which is most suitable to each. The orchestra of the 
county asylum should be noisy, with a goodly proportion of brass 
instruments, clarinets, &c., and play dance music and melodies; 
overtures and symphonies are caviare to the general. On the stage, 
farces, childish pieces, harlequinades are the most acceptable. As 
regards dances more selection is perhaps necessary; the physician, how¬ 
ever, should be as responsible for the dose of pleasure prescribed for 
each patient as for his medicine, and experience proves that a good deal 
of liberty may be given with advantage. Dr. Naecke carefully considers 
the question of the admission of strangers to asylum entertainments; 
curiosity merely should not be gratified, but it is an advantage that 
those who are interested in the insane should be invited; some of the 
prejudice against asylums which exists among the public may disappear 
as a result. 

On the question of refreshments, unquestionably total abstinence 
from alcohol would benefit the community as a whole, but Dr. Naecke 
believes that the danger of alcohol is exaggerated ; a pint of very light 
ale, which is the allowance to workers at Hubertusburg, is quite 
harmless, even to epileptics. The difficulty is to find a good substitute 
for alcohol as a beverage. 

Excursions and walks outside the asylum should be enjoyed by a 
large percentage of patients, and in this connection it is perhaps fair to 
utter the paradox that “ the greater the number of escapes, the better 
managed is the asylum.” 

A good deal of latitude may also be extended to patients in the choice 
of books, newspapers, &c.; they should not be treated as children. In 
acute cases (melancholia especially) some care must be exercised, but 
in Dr. Naecke’s experience even the perusal of unfounded adverse 
criticisms of asylums in the daily press, by patients suffering from 


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1899] 


NOTES AND NEWS. 


189 

delusional insanity, was not followed by any bad result. The same 
applies to correspondence ; the superintendent of an asylum should be 
as liberal as possible; to withhold all letters which comment unfavour¬ 
ably upon the asylum is a sign of weakness. 

Throughout the author is imbued with the idea that in dealing with 
the insane, one should extend the principle of no restraint to their 
moral treatment, and therefore to their diversions. Patients should not 
be treated as children, but like adults, and as far as possible one should 
respect their manhood and mode of life as in the days of their liberty. 
“ Let us not forget that what characterises a modem asylum is not so 
much its splendid external and internal appearance, not that it is well 
warmed and lit by electricity, but the spirit which presides there, the 
great principle of no restraint in its various shades which should 
pervade even the marrow of the physicians and the staff.” 


Part IV.—Notes and News. 


MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN 
AND IRELAND. 

GENERAL MEETING. 


A General Meeting was held at the rooms of the Association, 11, Chandos Street, 
London, on Thursday, 13th October, at 4 p.m., under the presidency of Dr. 
Urquhart. Meetings of the Educational Committee and of the Council had been 
held earlier in the day. 

Members present at General Meeting:—A. R. Urquhart (President), T. W. 
McDowall, Ernest W. White, James Chambers, H. Rayner, T. Outterson Wood, 
Fletcher Beach, H. Corner, H. C. MacBryan, A. Helen Boyle, W. Ernest Jones, 
Chas. Mercier, W. Douglas, T. W. MacDonald, Margaret Orange, F. Parris Piper, 
L. Rutherford Macphail, T. Seymour Tuke, R. Brayn, R. Langdon Down, W. 
Rawes, H. Stilwell, D. Bower, R. Baker, Alonzo H. Stocker, W. Julius Mickle, 
W. Crochley Clapham, L. U. Weatherly, C. K. Hitchcock, James Stewart, G. E. 
Shuttleworth, J. Peeke Richards, A. H. Boys, J. C. Gayton, H. J. Macevoy, R. 
Percy Smith, Harry A. Benham, R. L. Rutherford, G. H. Savage, H. H. Newington 
(Treasurer), Frank A. Elkins, Herbert Smalley, Robert Jones (General Secretary). 

Apologies for non-attendance were received from Drs. Spence (Registrar), 
Moody, and Soutar. 

The following were elected ordinary members: — Daunt, Elliott, M.R.C.S., 
L.R.C.P., D.P.H., Rosendale, Sevenoaks, Kent; Eades, Albert J., L.R.C.P. and 
L.R.C.S.I., Assistant Medical Officer, Borough Asylum, Nottingham; Longworth, 
Stephen G., L.R.C.P. and L.R.C.S.I., Medical Officer, County Asylum, Melton, 
Suffolk; Mackeon, W. J., A.B., M.B., B.A.O.R.U.I., Assistant Medical Officer, 
Menston Asylum, Leeds; Redington, John, L.R.C.P. and L.R.C.S.I., Assistant 
Medical Officer, Richmond Asylum, Dublin; Rochfort-Brown, Herbert, M.A., M.B., 
B.Ch.Oxon., F.R.C.S.Eng., Medical Officer, Natal Government Asylum, Pieter¬ 
maritzburg, Natal, S. Africa. 

The replies from honorary members elected at last annual meeting were read. 

The Handbook. —Dr. Hayes Newington, as chairman of the Handbook Com¬ 
mittee, reported as follows :—“ I have to report that the committee appointed a 
year ago has now finished its labours, after much consideration as to how far the 
book should be revised or rewritten. We think it now as good as can be expected, 
having regard to the great number of opinions that had to be satisfied. It has been 


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[Jan., 


considerably enlarged, and 6000 copies have been ordered. It is now on sale, and 
the publishers are the same as before.” 

Dr. Rayner proposed a vote of thanks to Dr. Newington especially, and to the 
other members of the committee for the work they had done. Seconded by Dr. 
Douglas. (Carried unanimously.) 

Papers were read by A. Helen Boyle on “ A Case of Juvenile General Paralysis ” 
(see page 99); by Reginald H. Noott on “ The Responsibility of the Insane: should 
they be punished? a reply to Dr. Mercier” (see page 53). A communication on 
“ The Macroscopical and Microscopical Appearances of the Uterus and Appendages 
in the Insane,” by J. Gordon-Munn, was not read as time did not permit (see 
page 23). 

The members dined together after the meeting at the Cafd Royal, Regent Street, 
W. f at 6.30 p.m. 


SOUTH-EASTERN DIVISION. 

The Autumn Meeting of this division was held at Springfield House, Bedford, 
on 10th October. From 12 to 1 p.m. the members inspected the asylum and its 
grounds. From 1 to 2.30 p.m. members partook of luncheon. At 2.30 p.m. the 
Divisional Committee of Management was held, and at 3 p.m. the General Meeting 
took place. Present—Drs. Urquhart (President), Ernest White (Hon. Div. Sec.), 
Haslett, J. P. Richards, D. Bower, C. H. Bond, R. Langdon Down, J. Bayley, 
J. M. Moody, A. S. Newington, R. P. Smith, F. Beach, G. E. Shuttleworth, T. S. 
Tuke, J. B. Emmerson, and J. Neil. Visitors—Messrs. W. G. Bower and P. Craig. 

The minutes of the last meeting were taken as read, having been printed in the 
July number of the Journal, and they were duly signed by the chairman. 

Letters regretting absence were read from Drs. Nash, Hicks, O. Wood, Rayner, 
Stocker, and Mr. Marks. 

Next meeting .—The Hon. Sec. stated that at the Spring Meeting they should 
visit a county or borough asylum south of the Thames. It had been proposed in 
committee that they should visit the East Kent Asylum at Chartham, to which of 
late considerable additions had been made under Dr. Fitzgerald. The proposition 
was adopted. 

Dr. Bower read a paper on " The Inadequate Asylum Provision for the Insane 
immediately above the Pauper Class” (see page 6). 

Lunacy Legislation. 

Discussion opened by Dr. White on ” Prospective Lunacy Legislation.” 

Dr. White said the object of this discussion was evident. He felt, as they all 
did, that when they next met in April most probably the Bill, by which they would 
have to stand or fall, would have been presented. It was therefore very necessary 
that what was to be said should be said now. He proposed to discuss the Bill as it 
came out from the Standing Committee of the House of Lords. All those little 
clauses which had been wiped out they could let lie, and they could briefly deal in 
the short time remaining with the clauses as they stood in the amended Bill. He 
proposed to open out to them the most important clauses. Four days had been 
substituted for seven days in the urgency order, and they would hear how the three 
days’ system had worked in Scotland, and how the urgency order had worked under 
the seven days’ system in England. But they might rest satisfied that four days it 
would be in England, because he was informed that the Lord Chancellor was abso¬ 
lutely determined on that point, and therefore any resolution they passed dealing 
with that question would, he feared, be without effect. The Lord Chancellor was of 
opinion that the urgency orders had been abused in the past to save the time and 
trouble of medical men and others; therefore he had introduced not only that 
reduction of the duration of urgency orders, but also the penalty which attached to 
the abuse of them. Clause 2 affected the duties of the authorities (reception order). 
He had had experience with magistrates’ clerks and others, and had found that 
they had been in the habit of extracting considerable fees when they had been called 
in for these cases, and the object of this legislation was to deprive them for the 
future of these fees, as someone was of opinion that they had been extracted in 
rather an excessive manner. 5. In the past the authorities had been in the habit 
of removing lunatics to the union, and keeping them there indefinitely; they were 


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sometimes kept there as long as possible, and of course that interfered with the 
prospect of their recovery. But for the future the Lord Chancellor was of opinion 
that they should not be detained for more than three days. Then came Clause 6, 
the disqualifications for signing the certificate, which was a most objectionable 
clause, as it interfered with signing for one's own relatives, and stated that any 
person attached to a licensed house could not sign certificates for patients of that 
licensed house to go to any other. In the early Bill, before it was revised in Com¬ 
mittee, a medical man in any way attached to a licensed house was disqualified from 
signing for any licensed house. 10 confers power to deal with the property of 
lunatics where it was extremely limited. 13. With regard to the reception of 
boarders, they all knew how they had been received in connection with licensed 
houses and hospitals for the insane; but they had never to his knowledge been 
received at county asylums. He doubted very much whether that power, if granted, 
would ever be availed of, because he considered it most detrimental to the good 
working of county and borough institutions to have boarders more or less free from 
the defined responsibility of the institution. Clause 14 stated definitely that the 
number of patients to be received into the old hospitals should be fixed. He 
thought in the past that the number received had been very elastic. There had 
been the parent institution and various others attached thereto, all of which were 
considered part and portion, and could receive patients. But the number had now 
been definitely fixed as it was for a borough asylum or licensed house. Clause 15 
was a very important one because it affected the rules and regulations. It gave a 
very much extended power to the Commissioners, and he dare say there would be 
those who thought they had that power before, but did not avail themselves of it. 
1 6 affected the management of hospitals. If it was not satisfactory it defined what 
was to be done, and how the regulations were to be carried out. 17 affected branch 
establishments. As he said before, the number of the patients in these had been 
very elastic, but by taking up the branch establishments as well as the hospitals it 
dealt definitely with them all, considering them as part of an asylum or hospital. 
No patients were to be received in the first instance into a branch establishment, 
and it may be visited by one Commissioner only. Clause 19 was very important, 
because it had been extremely modified in Committee. In the first Bill it stated, 
speaking from memory, that it was beyond the power of the committee of asylums 
or hospitals to utilise any portions of those institutions for objects other than those 
for which they were originally intended; that was to say, in the event of an epidemic 
they could not utilise a day-room for dormitory space for the time being, and vice 
versd. That was put before the Lord Chancellor as an extremely objectionable 
clause, and the clause had been modified. Of course the object of the original 
clause was to prevent any of them using part of their day space so as to increase 
their accommodation generally; but when he saw the difficulty with regard to 
temporary use, the Lord Chancellor introduced the clause as it now stands, so that 
they could use it for the time being; but they would have to get the sanction of the 
Commissioners subsequently. 20 affected corporate bodies acting in unison and 
afterwards wishing to separate. The Three Counties Asylum had been combined, 
but they were gradually drifting apart. Then there was a clause regarding the 
payment of patients to which he was bitterly opposed. He was happy to say that 
the large majority of superintendents sided with him, and after representation to 
the Lord Chancellor it had been withdrawn. 21 affected pensions and allowances. 
That had been a very vexed question. More than ten years ago they had a very 
large meeting, and he (Dr. White) proposed then, on the 16th of May, 1888, that a 
clause be added to the existing pension clause making the modified Civil Service 
scale compulsory as a minimum. It was extremely pleasing to him that this was 
the very clause the Lord Chancellor had adopted after ten years. That distinctly 
fixed the minimum: they could give up to two thirds salary and emoluments, but 
they must give one sixtieth for each year’s service. Then came the clause with 
regard to injuries to officers and servants. That was undoubtedly a considerable 
acquisition. It remained practically as it did in the Bill. It covered those who 
were injured in the actual discharge of their duty. 24 was with regard to offences 
against patients, and extended to those in workhouses. He thought he had now 
touched upon the most salient points in the amended Bill, and it would undoubtedly 
be reintroduced in the House of Lords very early next session in this form. There 
was another matter for consideration—the treatment of incipient insanity. A com- 


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mittee had been sitting upon that subject for two years, and had provided a clause 
for the temporary care of incipient cases. This unfortunately was surrounded with 
considerable difficulties. It worked all right in Scotland; but he was afraid in 
England they were more litigious than in Scotland, and he saw great difficulties in 
getting the Lord Chancellor to introduce it. It nominally did not take away the 
liberty of the subject, but in reality it must do so, or the patient was not properly 
treated. An effort had been made to get it introduced into the Bill, but he was 
personally more than doubtful whether the Lord Chancellor would do so. He had 
made these few remarks on the Bill because he felt the intense importance of 
speaking before it was too late. 

The President said the meeting would agree that their findings that day should 
be committed to their representatives on the Parliamentary Committee. He thought 
it desirable to confine the discussion in the first place to four important points. 
With regard to the duration of the urgency order: in Scotland it was three days. 
There the asylum medical officers were permitted to sign the certificate of emergency 
themselves, so that when a patient was brought in they could detain him for three 
days. That of course was a grave responsibility, and they very seldom used that 
power. In Scotland too the magisterial authority was different from England. 
They did not have to go any great distance to find the sheriff, and they had no 
trouble in finding him, because he must always be represented, either by himself or 
his substitutes. 

Dr. Richards said if the judicial authorities were about to be increased, then he 
thought the necessity of the urgency order somewhat diminished, because they 
would be able to get at a magistrate at once. Was it therefore worth while to 
object to the diminished number of days? He would move, “That if the judicial 
authorities are adequately increased the urgency order is not necessary, and should 
be deleted from the Act.” Mr. Bayley seconded. 

Dr. Bower said it would be a great inconvenience to have the urgency order 
absolutely abolished. It was an improvement when it was adopted, and it ought 
to be continued. He would propose as an amendment, “ That in the opinion of 
this meeting the urgency order ought to be allowed to stand as it is, and not to be 
restricted to four days.” As restricted it would be a very short time to get all the 
papers completed. 

Dr. Percy Smith seconded, saying that he did not know what they would do 
without the urgency order as it stood, as they so often could not find a magistrate 
when wanted. 

Dr. Haslett supported the amendment, and stated that the then Lord Chancellor 
was legislating in this respect against the advice of the Commissioners. 

Dr. White said he was informed that they were wasting time if they supported 
the amendment, as he had already pointed out. The extension of the judicial 
authorities would abolish the abuse of the order which had existed in the past. 
He had received under urgency orders any number of patients who had not 
required them, but four days would make it so short a period that they would be 
less resorted to, and in addition to that there was a penalty. Dr. Bower’s amend¬ 
ment was then put to the meeting and lost. 

Dr. White moved, “That the suggestion of the Bill, four days, be approved by 
the division.” 

Dr. Beach seconded. 

Dr. Bower said it was a case of urgency order or no urgency order, and not 
having had his own way he should now vote for Dr. White’s amendment, which 
was then put and carried. 

The President said the next point was as to the detention of patients in work- 
houses for three days. 

Dr. Smith moved, “ That not being adequately informed on the subject, the 
Division do not take it into consideration.” Dr. Richards seconded, and it was 
carried. 

Dr. White then moved, “That the clause fixing the minimum scale is acceptable 
to this division,” as leaving a sliding scale for merit, as not interfering with vested 
interests, and as protecting officers in the hands of unscrupulous committees. 

The President asked if there was any addition in sixtieths to the number of 
years of service. In the Civil Service it was held, in certain cases, that a man 
might be allowed so many years in addition to come for his education. 


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Dr. White said he was afraid there was no promise of that. 

Dr. Richards said he thought it was a most important question, and something 
might be done, in this respect by the Association. 

Dr. Bower said he did not think that clause contemplated the service of an 
assistant medical officer under more than one authority. Could they do something 
to strengthen the hands of the Parliamentary Committee ? He moved that they 
“ approve of the Pensions section of the new Bill, but would suggest its amendment 
by making previous service in other county or borough asylums count." 

Dr. White said he would withdraw his motion in favour of that, and seconded 
Dr. Bower’s proposition, which was carried. 

Dr. Moody said he did not know whether he was too late to reopen the question 
of the one sixtieth for each year. He thought it too low, and he would propose 
that " one fortieth be the minimum,” as he felt very strongly that if they could they 
ought to endeavour to obtain the substitution of one fortieth for one sixtieth as a 
minimum. 

Dr. Bower said he would agree to incorporate that in his motion, and Dr. White 
concurred. This, therefore, became the finding of the division. 

Mr. Bayley said that his committee had fully discussed the matter, and they had 
been asked in a communication from opponents to the Bill to go carefully through 
the clauses, but they felt that they were not inclined to offer any opposition. They 
felt that any suggestions made by the Commissioners were almost always for the 
benefit of the patients and the asylums. He had always found, throughout his long 
service at St. Andrew’s Hospital, that the Commissioners had always supported him. 

Dr. Percy Smith said they at Bethlem Hospital had also received the same 
communication, but felt that there was no need to take active steps in opposing 
the Bill. 

Dr. Seymour Tuke said that he was sorry to see that the gist of the whole 
Bill seemed to be conceived in a spirit of suspicion. He was very much struck 
with the wonderful amount of confidence which existed in Scotland between the 
authorities who made the laws and the medical men who carried them out. 

The President said that before they left that roof they would certainly desire to 
express their very warmest thanks to Mrs. Bower for having taken so much trouble 
to make their meeting a success (applause). He was sure Dr. Bower would under¬ 
stand how very much the Division appreciated his kindness and hospitality. 

Dr. Bower said it had been a great pleasure to him to receive the Division there. 
He felt it was a great honour that they should have visited Springfield House as 
the first private asylum. 

The members and visitors subsequently visited Bunyan’s cottage and Elston 
Church en route to Bedford, where they dined together at Roff’s Dining Rooms. 


SOUTH-WESTERN DIVISION. 

The Autumn Meeting of this Division was held at the Grand Pump Room 
Hotel, Bath, on Wednesday, October 19th, under the Presidency of Dr. Urquhart. 
There were also present Drs. Benham, A. Newington, Aveling, Lindsay, Blachford, 
Goldie Scott, Noott, Craddock, Bristowe, Wade, Fox, Douglas, Weatherly, 
Soutar, Barraclough, Sproat, Morton, Stewart, Cobbold, and the Hon. Secretary 
(Dr. P. W. MacDonald). 

Geoffrey Hungerford, L.R.C.P., L.R.C.S., Assistant Medical Officer, County 
Asylum, Dorchester, was admitted a member of the Association. 

Letters of apology for non-attendance were intimated from Drs. P. Warry Leas, 
H. Manning, and Briscoe. 

The minutes of the last meeting were held as read. 

Next Meeting .—The Hon. Secretary said that he had not yet received any 
invitation, and he was instructed by the Committee of Management to suggest 
that the arrangements be left to them and the Secretary, as was done last time. 
The meeting would, as usual, be the third week in April, Tuesday 18th. 

Discussion : Dr. Blachford’s Paper. 

Having stated that this paper had been published in the Journal for July, and 
having reviewed the salient conclusions which Dr. Blachford drew, the President 
called upon 

Dr. MacDonald, who said he would confine his remarks to one or two heads, 

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for, as all knew, the causes of mental disease were legion. In mentioning alcohol 
in that city so famed for its waters, one need not hesitate to take exception to the 
remark so often heard on the teetotal platform that alcohol was filling our asylums. 
Apologising for the district from which he came, he had to contradict that state¬ 
ment, for over a very long series of years he found less than 5 per cent, of the 
cases brought under his notice were due to alcohol. Dr. Blachford had worked it 
out to 8*2 per cent., but it had to be borne in mind that those figures dealt with a 
city, which was totally different to an agricultural district. But how did these 
figures compare with the returns of the Commissioners in Lunacy? The per¬ 
centage due to alcoholism taken from the Blue Book was 15*2—in his opinion 
another example of the fallacy of basing calculations on general statistics. Each 
district should apply itself to finding out the percentage of alcoholic cases, which 
varied so much in different parts of the country. He hoped no one would go away 
with the idea that he did not recognise in alcohol a great cause of disease, but what 
he did take exception to was the attempt on the part of many to hold it up as the 
one great cause of mental disease; yes, and in districts where reliable statistics 
could prove it was not. If by causing poverty, misery, and anxiety, alcohol 
indirectly produced disease, then we are agreed; but it was an entirely different 
thing to say alcohol was filling our asylums. He had been greatly struck with 
Dr. Blachford's observation as to the relation between syphilis and general 
paralysis. There was a time when every general paralytic was labelled syphilitic, 
and he had once heard an eminent authority actually say so. But this same 
authority had changed his opinion, and did not hold that view now. Another 
point of great importance was the few juvenile or developmental general paralytics 
met with at Bristol. In the course of ten or twelve years he had met with 
some six or seven, and the conclusion he had come to was that he knew of no 
reason why one should not be born a general paralytic any more than a syphilitic ; 
and he thought many of the hopeless idiots who had been classed as idiots were 
nothing more or less than general paralytics. If we admit—and I am hopeful it is 
admitted — that general paralysis may be an inherited disease, then I think heredity 
must play an important part in juvenile general paralysis. I now come to the 
last and most important cause mentioned, viz. heredity. Dr. Blachford said the 
percentage of heredity was 33. His opinion was that one half of their patients 
were foredoomed from heredity, for he was quite convinced it was only in a few 
of their cases that they got the slightest reliable information on this most 
important point. He did not mean that it was necessary the father or mother 
should hand down the insane cell to the son or the daughter, but there was a pre¬ 
disposition to insanity; and it was this predisposition they claimed to exist. 
Professor Virchow, in his Huxley Lecture, reiterated this view of the matter. 
His opinion was that so long as they propagated the species by the marriage of the 
tainted, the defective, and enfeebled (sowing broadcast the seeds of degeneration), 
so long would these cases multiply and their asylums fill, till the burden became so 
great that the ratepayers of this country would have to turn to the Legislature for 
help. It was from them (the medical profession) aid and advice would be sought, 
and it was for them now to show what was taking place in the country districts and 
large cities as well. On a former occasion he had offended by speaking plainly on 
the question of alcohol as a cause of insanity, and he hoped Dr. Stewart would not 
get him into trouble that day. 

Dr. Stewart said that much greater importance was sometimes assigned to our 
expressions of opinion than we intended, and when Dr. MacDonald said that it was 
not alcohol that was to blame but poverty and insanitary conditions and the misery 
afflicting unfortunate Dorset hinds which led to so much insanity, he might some 
day regret his expression of opinion if translated to mean that he went and flouted 
the alcohol theory. He (the speaker) did not want to say that alcohol was the 
destroyer it was often represented to be. He had no greater repugnance for 
anything than for the claptrap orators and the teetotal platform; but one might 
out of that repugnance fall into the other extreme. Supposing he was right in 
saying that they were doing what they could to point out to the general public 
how they might nullify the results of inheritance, and were doing their best for the 
good of the people, then he maintained they must look to other causes besides 
those to which Dr. MacDonald had referred. One of the causes he had not 
referred to was that rush and push which are so prominent characteristics of the 

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present day. People to insure something like a successful career considered it 
necessary to help nature to perform her functions. It was usual for the medical 
man to tell his patient he required stimulant, and as the power of the medical man 
was enormous, alcohol was taken. He had been trying to get it known that there 
were other things that could stimulate a man beside alcohol. The stimulant he used 
was food, and alcohol was not a food ('* Question ”). He thought that they would 
be right in accepting as the percentage of cases in which alcohol was the cause of 
insanity—something more than the figures Mr. Blachford gave, and something less 
than those of the Commissioners. 

Dr. Soutar said that he was sure neither Dr. MacDonald nor anybody was 
prepared to contend that alcohol in excess would not induce mental degeneration. 
But the important fact was whether it was in their community inducing the amount 
of mental disorder that had been asserted. It was perfectly clear that the per¬ 
centage varied with the locality. During the last five years at Barnwood House 
there had only been two admissions caused by alcohol. Often on consideration of 
cases it was found there were various co-operating causes. To be able to lay the 
finger on one single cause was very rare indeed (Hear, hear). Poverty and anxiety 
were co-operating causes with alcohol. He gathered that Dr. MacDonald meant 
that the distress was more effectual than the poison in inducing the insanity in a 
drunkard’s family. Dr. Blachford had confirmed the opinion long held that 
heredity was the great predisposing cause, and had shown there were all sorts of 
exciting causes capable of inducing the attack. All sorts of ordinary maladies 
induced mental disease in the already unstable. 

Dr. Barraclouqh provided statistical information as to the insanity of Wiltshire, 
and remarked that the statistics of the Commissioners were compiled from infor¬ 
mation furnished by the relieving officers, who took no trouble to get at the 
conditions of life of the patient. His experience led him to express his accord 
with Dr. MacDonald in the question of the causation from alcohol. It played a 
very much less part in the causation of insanity than was usually asserted. As 
regarded syphilis and general paralysis most people would now agree that syphilis 
had much less to do with it than was generally supposed, and that in spite of the 
statement of Dr. Noott that it was evident in 75 per cent, of the cases. Wiltshire 
was for long the county in England with the greatest proportion of insane. Now 
it was bracketed fourth, having 1 lunatic in 290 of the population. Intermarriage 
was responsible for a very large amount of the insanity which existed. In the old 
township of Caine it was said that every individual was related to everyone else; 
and although that was an exaggeration, it showed there was a large amount of 
intermarriage, and the result was the proportion of lunatics instead of being 
1 in 290 was in the township of Caine 1 in 189. In crime Wiltshire stood 
unfavourably, and nine out of ten cases were of an immoral nature. The character 
of the county he thought supplied the explanation. There was a lack of railway 
communication, and many places were miles removed from any station. Conse¬ 
quently stagnation existed, all the brightest intellects left the flotsam and jetsam 
of humanity behind. 

Dr. Noott said it was extremely difficult to get at the facts because friends 
either carelessly or wilfully kept facts back. He did not think that there was much 
doubt alcoholism would cause an insane inheritance. Alcohol would bring about 
mental debility. There was nothing that could be so clearly demonstrated as the 
effect of alcohol on brain tissue, and it must therefore be a cause of insane 
inheritance. Their proportion at Broadmoor of cases caused to some extent by 
alcohol was just over 22 per cent., but in almost all these cases the question of 
heredity applied. Alcoholics were often the children of epileptics. 

Dr. Benham said as the paper they were debating was prepared at the Bristol 
Asylum, he was naturally in accord with what Dr. Blachford said about alcohol. 
What was forgotten was that alcohol was very often the symptom of disease rather 
than the cause. He had been consulted twice within the last few months in regard 
to the marriage of persons who had been insane; and where pronounced insanity 
had existed, he had advised against marriage. Arrayed against his opinion were 
some of the great authorities of the county, and their views were brought under 
his notice in one case by the parent who consulted him. These opinions did not 
cause him to change his own. In one case his advice was taken, and in the other 
it was not. This showed that when one had strong views on the subject, he might 

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[Jan., 


do something for the future purity of the human race as it was their duty to do- 
He wished to bear testimony to the accuracy with which that paper was prepared, 
particularly with regard to the heredity statistics. Every case in which doubt 
existed was excluded, or at least the doubt went against heredity rather than for it. 

The President said he thought, from the tone of the meeting, they had pretty 
well made up their minds that the incidence of alcohol in regard to insanity had been 
much overrated (Hear, hear). They had been placed in possession of facts by Dr. 
Blachford and Dr. MacDonald, and he was sure that neither gentleman would have 
given them to the public had he not been absolutely sure of his ground. Their 
statements were in accordance with the general average of other institutions. 
What fell from Dr. Barraclough was specially interesting, because there was no 
county where statistics were so well dealt with as Wiltshire in the days of Dr. Thumam. 
He hoped Dr. Barraclough would bring forward a paper dealing with the time 
since Dr. Thurnam published his last calculations. With regard to the incidence 
of syphilis, the further east they went apparently the more convinced were 
physicians that syphilis was the cause of general paralysis. Although a consider¬ 
able proportion of the general paralytics under his care were undoubtedly syphilitic, 
he should not insist on such an extreme statement unless there was an absolute 
history obtainable. He did not see that it was practical to revive ancient laws to 
restrict the propagation of the race to the exclusion of the insane. Only the other 
day he was consulted by a clergyman who was about to marry a person whose 
family was steeped in insanity and neurotic maladies. He could not be induced to 
break the engagement even in view of the whole circumstances. And that was his 
usual experience in regard to this great wrong. It was curious that their discussion 
should touch this question, for while in the Abbey that morning he had chanced on 
the monument to Malthus, with its long and appreciative inscription. 

Dr. Blachford replying, agreed with Dr. MacDonald that the percentage of 
alcohol was very often exaggerated; but that was not surprising. The Commis¬ 
sioners’ statistics were based on figures supplied by relieving officers, to whom the 
cause was nearly always given as alcoholism, or not known ; even then, instead of it 
being so returned, it was attributed to alcohol. In many such cases evidence of 
prior insanity was afterwards found. With reference to Dr. Noott’s statement of 
22 per cent., he thought they naturally found drunkenness existing in the criminal 
classes, so that must not be taken to apply generally. 

Dr. Noott explained that the impression that the asylum of Broadmoor con¬ 
sisted of the criminal classes was quite erroneous; 81 per cent, were either 
murderers or would-be murderers, but the patients were not of the criminal class of 
the ordinary kind. They were simply criminals by the accident, having become 
insane and having committed a crime before they had been taken care of. There 
was a very large percentage of the lower middle class, and a very small number 
of the well-to-do. In the lower middle classes the relatives thought two or three 
times before they got rid of the breadwinner. In the upper classes, again, more 
care was taken to control the insane persons before they could do any harm. If 
people could only be induced to notice the first signs of lunacy, and to put the 
patient into their hands, Broadmoor need not exist. In reply to a question by the 
President, Dr. Noott said there was absolutely no trace of the incidence of alcohol 
in the well-to-do classes at Broadmoor. 

Lunacy in Private Practice. 


Dr. Bristowe read the paper on “ Lunacy in Private Practice ” (printed at 
page 66). 

Dr. Lionel Weatherly was to have followed with a paper on “ Lunacy and 
the Public,” but apologised for having been unable to fulfil his promise. He said 
public opinion, if that public opinion is based upon a knowledge of facts, is no 
doubt from every point of view a helpful thing towards a better legislation, but if 
that public opinion is only a mass of hysterical and emotional ideas in the minds of 
those who know nothing about the subject, and if such emotional ideas are 
embodied in new legislation, then that legislation must be pernicious. They must 
be agreed that English legislation in connection with lunacy had to a great extent 
been a legislation which had its foundation in hysterical ideas, and was pernicious 
in absence of knowledge of facts. It seemed passing strange to find, as one did 
find from practical experience, that the very people who would shout loudest about 


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their rights, and who wrote to the newspapers about taking away the people’s 
liberties, and perhaps, going further, said that the insane were placed where they 
were badly treated, that these were the people who, when insanity invaded their 
own family, were most indignant on discovering the red tape with which they were 
surrounded, and by which they were restrained in obtaining asylum treatment. If 
a person had to be sent to an isolation hospital because he was suffering from 
scarlet fever, the medical officer had not first to call to his aid some individual who 
knew nothing about the subject before he could be removed. But when anyone 
fell victim to mental disease he was hedged round with the legislation of ignorance 
before he could be placed out of harm’s way. Was it not time that they who knew 
should be heard in reference to the course pursued, a course which they recognised 
as having a pernicious influence on the persons affected with this disease? To 
come to private asylums, against which the cry has been loudest, " Oh, you ought 
to do away with them, because it is the self-interest of the proprietor to keep his 
patients as long as possible, and to get the most he can out of them ! ” It only 
required a man of common sense to recognise that self-interest acted beneficially. 
It was the interest of the proprietor of a private asylum to make the patient 
comfortable, to make the relatives contented, to maintain his reputation, so that 
there should not be a word said against him. There could not be a superintendent 
of any public asylum who felt so keenly that he should not keep a patient a day 
longer than necessary as the superintendent of a private asylum, because he knew 
the public could not accuse him of self-interest in the matter. 

He could not help feeling that if this unwarrantable suspicion was still allowed to 
grow the recovery rate of insanity could not possibly increase. They had once more 
neard that day how necessary it was that insanity should be treated early. How 
were they going to obtain that for the well-to-do classes if they were hemmed round 
with restrictions, and if the public were educated in these false beliefs ? The Com¬ 
missioners should lay more stress on the fact, and should let the public know it, 
that they see personally every insane person detained under the Lunacy Acts; that 
they speak to every one, and that they ascertain whether it was right that he 
should remain in asylum care. The Commissioners should let the public know that 
they have not found people in asylums who ought not to be there, and ought to 
refer to the efforts made for the welfare of the insane. If they did not do this, and 
did not educate the public, the medical profession would continue to be handicapped 
in their treatment of insanity. 

Dr. Murray Lindsay said that the shrewd and judicious remarks they had just 
listened to were just what they might have expected from Dr. Weatherly’s common 
sense. He agreed with everything he had said. There was no question that there 
was a great prejudice against public asylums, and particularly against private 
asylums. He had an experience in both, and his impression was that private 
asylums were, and had been for many years, very well conducted. They were more 
open to inspection than public asylums; there were more visitors. He had never 
seen the least desire to retain cases unduly even for one day. His feeling was that 
more harm had been done by premature discharge than by unnecessary detention, 
and there was a tendency to discharge cases prematurely. He had seen no case of 
unnecessary detention during his long years of service in Scotland and England. 
Public opinion was very prejudiced and very strong against asylums. He had often 
met with people who had said they could not send their relatives to a private 
asylum because of the pecuniary interests of the proprietor. He had always con¬ 
tested that, and he had even given it as his opinion that patients were safer in 
private than in public asylums. The Commissioners might do something more than 
they did, and asylum proprietors themselves ought to do something more to 
enlighten the public. 

Dr. Wade said that he heard Lord Shaftesbury declare that the Parliamentary 
Commission of 1877 had not discovered a single case of wrongful detention in an 
asylum, and yet the Lunacy Act of 1890 was passed positively without being dis¬ 
cussed. It would certainly be a great gain if the Lord Chancellor were to consult 
those who had practical experience in lunacy; but he had it from high authority 
that legislators did not want the opinion of experts. That being so he did not see 
what could be done. 

Dr. Weatherly. —Educate the public. 

Dr. Wade. —How can we? The public did not come to these meetings, but 

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might be reached through the medical press. Sometimes it was difficult to get the 
magistrates to certify, because the medical men could not make up their minds that 
the person was dangerous. They should impress on the profession the necessity 
of sending to asylums dangerous epileptics and persons with fixed delusions. 

Dr. S. Craddock said he held strong opinions on the subject of dangerous epi¬ 
leptics, but he had been very unsuccessful in getting them admitted to asylums. 
He had even had cases returned home from asylums, patients he considered ought 
to have been permanently detained. There was no class more dangerous. He 
remembered sending Dr. Wade one of these cases, but his certificate was returned 
for further details. As usual he sent it back, saying that he never added to or 
detracted from anything he had written. After much correspondence Dr. Wade 
received instructions to discharge the patient unless he could get a medical man to 
examine him further, and that medical man was not to be Dr. Craddock. As to the 
examination of insane persons bv the magistrates, it was generally of a most imper¬ 
fect character. He found when he went to give evidence there would be sometimes 
a magistrate who would not go into the case at all, and then another time there 
would be a magistrate who ignored the medical evidence, and tried to get information 
for himself, in which he was very rarely successful. He had under his care in the 
Bath workhouse a considerable establishment for imbeciles. Occasionally it 
happened that they became violent, and he had to transfer them to the asylum. 
He had set his face against their being brought to the Guildhall, two miles away, 
which was the course of procedure advocated by the magistrates and the board of 
guardians. The magistrates did not like going to these cases at all, and still less 
when they had to go two miles uphill. The board of guardians saw no reason why 
he should take up that position, but the Local Government Board and the Com¬ 
missioners in Lunacy fully supported him. Something ought to be done to make 
magistrates go to the insane instead of having them put into the dock like criminals. 
If they undertook the office of the justice of peace they should be prepared to carry 
out the duties in a proper manner. 

Dr. Soutar thought many of Dr. Weatherly’s remarks open to question, as to 
whether, for instance, public opinion was not, upon the whole, healthy. If public 
opinion had been altogether influenced by those who were in charge of asylums it 
might have happened that their present position would not have been so good as it 
was. After all, the liberty of the subject was a sentiment to be upheld, and if it 
had been exaggerated it was better it should be exaggerated than disregarded. He 
could not see that the Act of 1890 had done much to retard their work. As many 
came into the asylums now as before. The difficulty was, just as often as not, that 
the doctor would not certify. Now and again the magistrate would overrule the 
opinion of the doctor, but that was rather exceptional, and so long as they had 
human beings to deal with they must expect such incidents. With regard to 
public and private asylums, he thought there was room for both. Certain patients 
were better in a good private asylum and others in a good public institution. It 
was a question not so much whether it was a public or a private asylum, but 
whether it was a thoroughly well-managed asylum. If the best was done for the 
patient it did not matter whether it was public or private. 

Dr. MacDonald said he had listened with very great pleasure to Dr. Bristowe’s 
able paper on an interesting subject, and he could not help recalling to their minds 
the early days of this Division, and Dr. Bristowe’s profound scientific communica¬ 
tions. Reference had been made to the lingering prejudice against asylums, and 
he thought by no other means or method could this steadily decreasing prejudice 
be still further removed than by the teaching and advice of members who, like Dr. 
Bristowe, had first acquired a sound knowledge of mental disease and asylum 
treatment, and afterwards worked as general practitioners. It was thought that the 
urgency order might assist in the early treatment of mental disease, but as the 
superintendent of a public asylum he should be sorry were the urgency order to 
become applicable in the case of the ordinary county patient. He could not help 
saying that very often the delay was occasioned by the reluctance, if not inexperience, 
on the part of medical men themselves to sign the necessary certificates. Quite 
recently he had admitted a patient concerning whose case he had previously been 
consulted and advised special treatment, but owing to hesitation and delay on the 
part of the doctors, he (the patient) had made a determined attempt at suicide, 
after which he was hurriedly sent to the asylum. With regard to Dr. Weatherly’s 

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remarks, he thought, with Dr. Soutar, that many of his statements were open to 
criticism. He was of opinion that the best class of private asylum was, and always 
would be, required; at the same time they should not forget that for some con¬ 
siderable time legislation had favoured public control in the management and 
treatment of the insane. He failed to understand Dr. Lindsay when he said that 
private asylums were more open to inspection than public asylums, and that patients 
were safer in the former than the latter. It might be said, being a public asylum 
officer he was biassed, but he could assure the meeting he had a thoroughly open 
mind. If we could only teach the public to recognise asylums as hospitals for the 
treatment of disease, much, if not all, of our present difficulties and troubles would 
disappear. 

Dr. Benham, alluding to the attitude of the medical profession generally, thought 
the new regulation that all medical students had to spend some time in an asylum 
would be of great benefit, for future practitioners would be much better equipped 
with knowledge and able to sign certificates in difficult cases. Men going out from 
themselves as Dr. Bristowe had done would do much good, and only by the influence 
of such gentlemen amongst the general practitioners would the dislike of asylums 
be diminished. 

The President said that it was quite a pleasant surprise to hear the Act of 1890 
well spoken of. He had been for years under the impression it was a detestable 
measure. Why it actually conferred a monopoly on Dr. Weatherly, and he did 
not think anything could be worse than that! He was firmly of opinion that 
private asylums should be free to grow and to multiply. Let those that were worthy 
survive. Those that were not would soon go unaer. The central difficulty and 
vulgar error was that all insane persons were regarded with distrust and suspicion 
and aversion. It did not matter who had to deal with them, they were all in the 
same category. There could never be a better word than "asylum” for their 
purpose. What they had to do was to purify the public conception of it and not to 
change the name. As to the certification of the insane, it was a never-ending 
wonder to him that they found the medical men of England bold enough to 
certify. When it came to accurate diagnosis and weighing the pros and cons, in a 
difficult case as to whether a person ought to be certified or not, what medical 
man could be free from fears of future prosecution ? It was much easier to let 
difficult cases alone, but the daily newspapers showed the disastrous results. To 
make the discussion practical, was there anything the Division could do to mend 
matters in view of the Bill soon to be reintroduced into Parliament ? That was the 
question for them. 

Dr. Weatherly, in reply, said he was absolutely in accord with Dr. Wade, and 
members would remember he had spoken previously of their not hiding their light 
under a bushel. They should publish their views in the medical newspapers. He 
quite agreed that each asylum should stand on its own merits, for they got their 
patients how? simply by recommendation of former patients and their friends. 
That being so, there was no doubt the properly managed asylums would prosper. 
He maintained again that the very self-interest of which the public accused them, 
the private proprietors, was unquestionably the greatest safeguard for the patients 
and their relatives. 

The President pointed out that the superintendents of public asylums receiving 
private patients stood in no other relationship to their patients and their patients’ 
relatives than did the private proprietors. Any shortcoming in duty, still more any 
misdeeds, would come back on their own heads, and they would suffer just as 
keenly. 

The members afterwards dined in the hotel, which brought a most successful 
meeting to a close. 


NORTHERN AND MIDLAND DIVISION. 

A meeting of this Division was held on the 12th October, at the County Asylum, 
Mickleover, near Derby. 

Members present—Drs. Richard Legge, C. K. Hitchcock, J. S. Adair, S. 
Rutherford Macphail, W. S. Kay, James Middlemass, Alfred Miller, H. Harold 
Greenwood, and Crochley Clapham (Secretary). Visitors—Edmund Vaudrey, J. 
T. Story, John Richards, and r . B. Rackstraw. 


Rackstraw. 


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Dr. Legge was voted in the chair, and the minutes of the last meeting having 
been read and confirmed, the time and place of the next meeting were fixed for 
Wednesday, April I2th, 1899, at Hatton Asylum, Warwick. 

A paper on the “Thyroid Treatment of Insanity” was then read by Dr. 
Middlemass. (See page 40). 

The proceedings closed with a vote of thanks to Dr. Legge for presiding, and 
for his hospitality in providing lunch for the members. 

After the business meeting, the members of the branch were escorted through the 
wards of the asylum by the medical officers. 


SCOTTISH DIVISION. 


A meeting of the Division was held in the Royal College of Physicians, 
Edinburgh, on Thursday, 10th November, Dr. Urquhart, President of the Associa¬ 
tion, in the chair. Present: Drs. Clouston, Havelock, Hotchkiss, W. W. Ireland, 
Carlyle Johnstone, McDowall, R. B. Mitchell, Parker, Ford Robertson, Rutherford, 
James Rutherford, jun., Turnbull (Secretary), Watt, and Welsh. There were 
also present as visitors Drs. Ireland, junr., M‘Intyre, and Sturrock. 

Dr. George Arthur Rorie, Clinical Assistant, Royal Asylum, Edinburgh, was 
admitted as a member. 

Dr. Havelock opened a discussion on the Fatal Accidents Inquiry (Scotland) 
Act and the Workmen’s Compensation Act in their Bearings on Asylums (see 
page 15). 

Dr. Gilbert A. Welsh read a paper on “ Syphilitic Insanity,” which will 
appear in a future number of this Journal. 

Dr. Clouston said that he wished to direct the attention of the members to the 
Inebriates Bill, 1898, which would come into force in the beginning of next year, 
and which, although it applied only to inebriety with crime of some sort, embodied 
the principle that inebriety could be treated for long periods by the deprivation of 
the liberty of the subject for inebriety alone against the subject’s inclinations. If a 
man had been three times drunk and incapable he could be brought up, and in 
addition to being punished he could be kept for three years in an inebriate 
reformatory. At last what the medical profession had been contending for for 
many years had now come to pass, that an inebriate might be reformed against his 
will. That was one step, and the other was that under the provisions of this Act 
local authorities could take public moneys wherewith to set up inebriate reforma¬ 
tories. The Town Council of Edinburgh, at the beginning of 1899, could assess 
the ratepayers for an inebriate reformatory. Another part of the Act was not only 
for the criminal inebriate, but for the habitual drunkard. The Dalrymple Act had 
been stretched in different ways. The Colleges of Surgeons and Physicians in 
Edinburgh and Glasgow had combined in a representation to Lord Balfour, on 
whom, as Secretary for Scotland, was laid the duty under the Acts of making 
regulations and bringing them into operation. He had nominated five members 
of a committee for this purpose, but in the committee he had not included any 
medical opinion. It seemed to be most extraordinary that the regulations for the 
control of what was often a nervous disease were to be made by five lay members. 
That was a thing that they felt keenly, for it showed how little medical opinion 
had got into the minds of statesmen. This was a very important Act; its im¬ 
portance lay in the principles it embodied, and the certainty that these principles 
would be extended to all inebriates in course of time. In the title of the Act 


nothing was said about criminality; it was stated to be an Act for the treatment 
of habitual drunkards, although only applicable to those who had been convicted 
of being drunk three times. 

Dr. Urquhart said that he had asked Dr. Clouston to make this statement so 
that if anyone present had any suggestions to make, Dr. Clouston could receive 
and consider them. Had it not been for Dr. Clouston this important matter would 


have proceeded without comment. They had seen by the newspapers that this non¬ 
medical committee had been appointed, and it had been allowed to pass, as 
the medical profession almost invariably allowed these things to pass. It was 
largely their own fault that they did not weigh more in the political world. 

Dr. Carlyle Johnstone said that they should support the Colleges, and suggested 


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that a representation should be drafted by the Chairman and forwarded to the proper 
quarter. 

Dr. U rquhart pointed out that they must not commit the Association. 

Dr. Carlyle Johnstone said that they could commit the meeting, and he 
thought that would be in order. He therefore moved that the Chairman be given 
authority to show the feeling of the meeting in the proper way by communicating 
with Dr. Clouston. The motion was seconded by Dr. Rutherford, and was 
carried. 

After the meeting the members dined together as usual in the Palace Hotel. 

[We understand that Dr. Clouston's name has been added to the Committee 
under the Inebriates Act by Lord Balfour of Burleigh, the Secretary of State for 
Scotland, on the nomination of the three Scottish medical corporations.— Ed.] 


BRITISH MEDICAL ASSOCIATION.—EDINBURGH MEETING. 

Address in Psychological Medicine by Sir John Batty Tuke. 

Sir John B. Tuke heralded his address by drawing attention to the facts that it 
was the second upon this subject which the British Medical Association in annual 
meeting had demanded, and that the previous address by Sir J. Crichton-Browne 
(delivered in 1890) was the first address on Psychological Medicine in the history 
of the Association. That such a discourse should be required twice within eight 
years is indeed a striking proof of the important position which our specialty has 
taken of recent years in the hierarchy of the medical sciences. To some 
degree, perhaps, it is also due to the personal distinction of the deliverers of the 
respective addresses —men who have so largely contributed by their labours to the 
advance which these addresses at once denote and illustrate. 

The immediate topic with which Sir John B. Tuke dealt was “the modern con¬ 
ceptions of the etiology of insanity.” The study of the insanities in former times 
was surveyed in a not very sympathetic way. Our unfortunate predecessors must 
not be judged too severely, especially when we consider that they admittedly 
did not possess the data which now afford “starting-points to the psychiatric 
physician for the scientific study of his subject.” Unhappily, the art of medicine 
has often to be practised while knowledge is still very deficient, and the sad havoc 
which time has played with favourite views in general medicine which prevailed a 
quarter of a century ago, should make us modest in boasting of our advance. Sir 
John presented a telling contrast between the state of knowledge in 1864 and at the 
present dav. But it is only, as it were, yesterday that we were talking about the 
cortical cells as centres of energy, or else as storehouses for residual impressions, 
while now they are but victual stores — 

“. . . . And who doth know 

How long we please they may continue so.” 


Nothing is final in our knowledge; and, indeed, in cerebral anatomy and path¬ 
ology we have hardly yet reached beyond the initial stage. “ I verily believe,” 
says Sir J. Batty Tuke, “ that the changes of conception of the nature of the 
insanities is much more due £> the establishment of scientific data bearing on the 
antecedents of mental action than to the generalisations of the philosopher as to 
mental activities. . . . Gradually —no, I should say rapidly; perhaps too 

rapidly for complete assimilation—there has been presented to the physician know¬ 
ledge of a cerebral apparatus on which he is warranted in basing working hypotheses 
and practice. Until that apparatus was demonstrated he could not assert, except as 
an assumption, the fundamental physiological principle that mental action is a 
function of connection, or the pathological corollary that interruption of connection 
is the cause of impaired mental action.” The members of our specialty, “ knowing 
that they have a mechanism to deal with, solution of the continuity of which in any 
part of its course may affect its function, have a scientific foundation for the study 
of morbific influences productive of interruption of connection.” The great work 
which has been done of late years in the pathology of insanity was considered, and 
two illustrations of a general character are given of the good results from such 
study. “ In former times the theory of the effect of the jnind on the body held a 


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foremost place, and gave rise to many misconceptions. For instance, the general 
degradation of the system, the complications in the intestinal and reproductive 
systems, which are such marked and important symptoms in many of the insanities, 
were regarded either as the results of abnormal action or as its cause. Now that 
we recognise that the brain exerts trophesic functions over all the organs of the 
body, we are alive to the fact that such degradations are referable to imperfect brain 
action, that they are secondary on the reduction of its nourishing action, and are to 
be treated accordingly.” “ Another evidence of change is afforded by the accept¬ 
ance and extension by the psychiatrist of the principle that all mental symptoms 
are produced by the action of the same causes of disease which act in other systems 
than the nervous.” Sir J. Batty Tuke concludes by advocating warmly the modern 
hospital system of treating the insane. Incidentally he remarks, “ We know that if 
we exclude general paralysis and epileptic insanity from consideration, at least 
80 per cent, of recent cases are amenable to treatment.” We agree with his obser¬ 
vation that valuable time is often lost, particularly in England, where “the proce¬ 
dure for the transmission of insane persons to asylums is so absurdly cumbrous as 
to prevent many persons being placed under treatment until such time as the 
probabilities of recovery are seriously lessened or the case is hopeless.” 


Psychology Section. 

President’s Address.—The Neuroses and Psychoses of Decadence. 

Dr. Clouston, in opening his address, briefly referred to his corresponding paper 
of 1890 on “The Neuroses of Development.” One of these groups has as its cause 
a faulty development, the other an unphysiological decadence of the brain. As 
during development so during decay, one organ may change more rapidly than 
another. Thus in the latter case may be established a neurosis through unrelational 
decadence. The speaker glanced briefly at climacteric influence and the influence 
of neuro-vascular decay, and pointed out how in the life history of the neuron we 
see in its youth a susceptibility to external impressions, and in its age a liability to 
succumb to poisonous and degenerative agencies which are respectively character¬ 
istic. Heredity is not as powerful an agency in the production of decadent neuroses 
as in the origin of developmental. It seems to act in a different way. In the latter 
case it stops the reproduction of a bad stock; it is an actively destructive force. In 
the former it shows itself as a mere weakening of normal supports, so that the 
organism thus tainted yields unduly to the strain of life or to other morbid con¬ 
ditions. Comparing the statistics of the number of the population at a given time 
whose age was between 1 and 25, between 26 and 50, between 51 and 75, and 
between 75 and 100 with the proportion of deaths from nervous diseases occurring 
in each group, it appears that the neuroses prevail largely in the period of brain 
growth; that the best years of life are very free from them, and that decadence 
brings them on with a rush, senility being the most deadly neurotic period of all. 
The signs of nerve decadence, the clinical characters of the psychoses of old age, 
and the remarkable diminution in old age of the power of resisting toxic agents, 
notably alcohol, were dealt with at some length, and in Dr. Clouston’s usual impres¬ 
sive way. To him it appears that there are three types of nervous and mental 
lesions connected with decadence. First, those connected with vaso-trophic degene¬ 
ration. Second, the degeneration of the motor and sensory systems, which constitute 
the progressive degenerations. Third, the climacteric and senile insanities, in which 
the primary lesion begins in the mental tissues and mental areas. Dr. Clouston 
ventures on an hypothesis with regard to the history of senile mental decay. The 
mental faculties do not undergo decadence in the order of their development. 
Therefore probably the same is true of the cortical neuron. As the memory—the 
permanent recording of impressions—is the first to disappear, it is probable that the 
molecular structure of the protoplasm of the neuron is the first to suffer in decad¬ 
ence. Probably the gradual destruction of the dendrites and their gemmulcs and 
the neuraxons next takes place, and is the cause of decadent reasoning in senility. 


A Discussion on Suicide in its Psychiatric and Social Aspects 

was opened by Dr. Sibbald, who presented a series of most interesting statistical 
tables. From these it would appear that the figures for Great Britain show, as 
similar tables for most other countries do, a gradual though fluctuating rise in the 


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suicide rates during thirty vears. England and Wales show a rise from 67 to 86 
per million—an increase ot 28 per cent. Scotland in the same period rose from 4 0 
to 54 per million—an increase of 35 per cent. The rates throughout are con¬ 
siderably higher for England and Wales than for Scotland. It is suggested that 
suicide is of late more often regarded as dependent upon insanity, and is therefore 
not concealed so much as before. The various methods by which suicide is effected 
are analysed with very striking results. Hanging is the mode least open to error, 
either by concealment or mistaken diagnosis. In the fifteen years 1865-79 suicides 
by hanging amounted in England and Wales to 25 per million, in Scotland to 16 
per million. In the following fifteen years the rates were 24 per million in England 
and Wales, and 16 per million in Scotland. Statistics for shorter periods show, of 
course, more fluctuation, but no progressive increase. Dr. Sibbald has studied the 
rates for smaller areas in Scotland, and finds that the incidence of suicide varies very 
much in different localities, but that in each locality the ratio remains the same 
from period to period. He gives tables showing the number of deaths by firearms 
and cutting and stabbing for thirty years, also the deaths by poisoning and drowning. 
These tables show that the proportion of deaths per million from these various 
causes remain steady, but that of such proportion the proportion attributed to 
suicide has increased, and the proportion to accident has diminished. The 
conclusion to which the author of this most carefully worked paper comes is that 
with regard to suicide there has been really a wonderful steadiness in the rates, 
and that there is ground for believing that the apparent increase is due to the 
registering of deaths in recent times as suicides which would in former times have 
been registered as accidents. 

Dr. Haig discussed suicide as a result of error of diet. He regards melancholia 
as due to the circulation of impure blood in the brain—uricacidaemia or collaemia. 
If, he thinks, we could wipe out of our diet two substances, animal flesh and tea, 
we should almost completely eliminate its pathological excesses. Dr. Haig calls 
attention to special features in the depression of “collaemia,” such as that it is 
paroxysmal and temporary. He ingeniously accounts for this, as well as for diurnal, 
accidental, and annu^ fluctuations in melancholia, by explaining the various modes 
by which, under varying circumstances and conditions, the amount of uric acid 
circulating in the blood varies. A number of other influences—season, age, sex, 
various diseases, &c.—are, according to this view, if we rightly understand it, 
capable of being explained by varying conditions of collaemia. In fine, Dr. Haig 
holds that in diet lies the cause of suicide, and in a proper and scientific revision of 
diet lies the hope of prevention. 

Dr. Macpherson, Honorary Secretary to the Section, read an abstract of a 
communication from Professor Morselli, of Genoa, dealing principally with the 
classification of suicide. 

Insanities of Inebriety. 

Dr. J. F. Sutherland, Deputy Commissioner in Lunacy for Scotland, read a paper 
on “ The Insanities of Inebriety from the Legislative and Medico-legal Standpoint.” 
Dr. Sutherland counts inebriety high as a producer of insanity, placing it second, 
and that bv a short way, to heredity. Probably, however, those who attribute most 
weight to heredity would place the latter in an entirely different category from any 
cause acting in a sense externally. Dr. Sutherland seems to consider alcohol 
responsible for as many as 25 per cent, of all cases of insanity and imbecility which 
pass into asylums. He reviewed previous legislation on the subject cf the 
prevention of habitual inebriety, and held that the Bill of last Session could be 
improved by a clause prohibiting vendors from supplying alcohol (1) to certified 
inebriates who are put under recognisances, and not yet deprived of liberty ; (2) to 
certified inebriates on probation; (3) to certified inebriates, whether discharged on 
probation or not, for a period of three years thereafter. He believes that such 
legislation could be worked successfully in Scotland, yet he sees considerable 
difficulty in making it operate successfully in large towns. It appears to us that 
these difficulties would be very serious, taking into account the numbers that would 
need to be dealt with, and the extreme unwillingness of those charged with the 
administration of the law to go even within statutory limits beyond the demands of 
public opinion. Arguing on the remarkable difference between the prevalence of 
inebriety in towns, and its comparative rarity in countjw districts, a patent fact. 

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Dr. Sutherland plainly affirms that inebriety, whether criminal or non-criminal, is a 
•disease or vice, or both, for the vice long indulged ultimately ends in disease, and 
is in the main, like insomnia, neurasthenia, neuralgia, and hysteria, met with in 
large centres of population, and in great measure due to unhygienic and uncomfort¬ 
able surroundings, to the facilities for illicit sale, to vicious and contaminating 
■environments, to customs and habits lone practised in certain strata of society, and 
so forth. But if this way of looking at inebriety be correct, surely the duty of society 
should begin by endeavouring to get at the causes, and not by punitive measures or 
measures tending to restrict vice or disease already established. The liberty of the 
subject, says Dr. Sutherland, has become a fetish. A law to lessen the degradation 
and disgrace both of the individual and the community cannot be considered an 
invasion of liberty. So far, most modern thinkers whose eyes have been opened to 
the miseries produced by alcohol will agree with him. But he goes further, and in 
this probably few of us will follow him. He tells us that the criminal law in this 
country is far astray in regard to its attitude towards the authors of homicide, 
assaults, &c., committed by persons in a state of intoxication. Intoxication, he 
says, is insanity, fleeting it may be, but from the disorder of the senses and faculties 
producing as perfect a picture of insanity as is to be met with in the wide and 
•diversified range of lunacy. His feeling is that the plea of insane at the time is a 
proper special defence, or failing the acceptance of that, that the crime, after 
medical and other evidence has been received, should be reduced from murder to 
culpable homicide. 

At the conclusion of the discussion a resolution was moved by Dr. Sutherland, 
seconded by Dr. Yellowlees, and unanimously adopted, calling upon the Council 
of the Association to press the need of further legislation, and stating the opinion 
of the Section that no such legislation would be effectual unless it provides com¬ 
pulsory care for habitual inebriates from all classes of society, and unless it 
prohibits the sale of intoxicants to known and certified inebriates. We have not 
heard how this last clause of the resolution is to be rendered effective in actual 
working. 

The Phenomena cf Hypnotism and the Theories^Of its Nature. 

Dr. Milne Bramwell discussed the general bearing of the question of 
hypnotism at some length, and detailed a series of cases of his own illustrating its 
useful therapeutic effects. These cases were of great interest, but seemed to show 
nothing absolutely new. Dr. Bramwell has clearly been an assiduous worker in 
the field, and has had some results which are extremely encouraging and successful. 
What is new is his claim to have proved that the hypnotised subject is not at the 
mercy of the operator. This he says he himself at first believed, but finding that 
individual patients varied very much in their susceptibility to suggestion during 
hypnosis, he initiated a series of experiments on the volition in hypnosis. The 
plan he adopted was to question profound somnambules during hypnosis as to their 
own mental condition. Their replies showed that when in the hypnotic state they 
knew that they were hypnotised, but retained completely the sense of their personal 
identity and relationship with the outer world. They could reason as logically as 
in the waking state, and were confident that they could resist any suggestion that 
was displeasing to them. He gave some remarkable examples of persons refusing 
to adopt a suggestion made to them, whilst in the hypnotic state, to commit crime 
or even the semblance of crime. His conclusion was that not only is the volition 
unimpaired in hypnosis, but hypnotic experiments or treatment exercise no weaken¬ 
ing effect upon the volition in the waking state. Judging from his experience, Dr. 
Bramwell is of opinion that the employment of hypnosis by medical men who 
are acquainted with the subject is absolutely devoid of danger. Dr. Bramwell 
dwelt at length upon the various theories of hypnotism propounded since the 
time of Braid. He contested Bernheim’s notion that suggestion explains 
hypnotism, whereas suggestion is merely the machinery by which the phenomena 
of hypnotism are excited. He also strongly contended against the views prevalent 
in the Nancy school that automatism and weakened will characterise the hypnotic 
state. 

Mr. F. W. H. Myers, in a very polished discourse, dealt with what might be 
called the theoretic aspects of hypnotism. Though we must admire this author's 
skill in exposition, we cannot see that the idea conveyed in his elegant phrases 

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treating of ‘'supraliminal” and "subliminal” spheres of mental activity bring 
us much more forward than did the " unconscious cerebration ” of the school of 
Carpenter. Contrasting hypnotism and hysteria, he tells us that in hysteria we lose 
from supraliminal control portions of faculty which we do not wish to lose, and we 
cannot recover them at will. In hypnotism we lose from supraliminal control por¬ 
tions of faculty which we wish to lose or are indifferent to losing, and we can 
recover them the moment that we will. Comparing hypnotism and genius (" pro¬ 
ducts of subliminal mentation uprushing into ordinary consciousness with actual 
benefit to the waking life ”) he discusses the question whether hypnotism succeeds, 
in bringing up faculty from submerged strata into conscious control and enjoyment, 
and answers that to do this very thing is the essence of hypnotism. Again, in 
sleep we have a condition of shutting off of the supraliminal life of relation, of 
external attention, and the concentration of subliminal attention upon the pro¬ 
founder organic life. The first obvious effect of hypnotism is to bring sleep more 
fully under control. After glancing at sleeping-waking states, Mr. Myers said that 
the essential meaning of hypnotism is always the same—a fuller control over sub¬ 
liminal plasticity. Attributing the therapeutic effects of hypnotism to this fuller 
control over subliminal plasticity (the activities which are busy with organic as 
distinguished from intellectual life), and recognising that the phenomena of 
hypnotism are in the main due to suggestion, he tells us we need to ask what 
suggestion really is. It is not ordinary persuasion, that is clear. Mr. Myers 
believes that subliminal relations between man and man play a real part in the 
production of hypnotic phenomena. 

Other Papers. 

An instructive case of Hamatoporphyrinuria was reported by Dr. Hotchkiss, of 
Gartnavel. 

Drs. Kerr and Bois, of Hartwood, related the results of their trials of spleen and 
thyroid extract in the treatment. Twenty-two patients were treated with spleen extract. 
Mental recovery occurred in eight, physical improvement in seventeen. The most 
favourable cases appear to be adolescent males suffering from stupor. The mode of 
use recommended is by capsules of fresh liquid extract, twenty grains in each. 

Dr. W. Bernard read a paper on the need of recognising weakmindedness early 
in children, and pointed out that more distinct criteria of this condition at the 
earliest period of life were needed. 

Drs. Dawson and Rambaut read a valuable paper analysing the ocular pheno¬ 
mena in forty cases of general paralysis. 

Dr. Hogben read a paper on pauper lunatics in private dwellings in Scotland. 

Dr. Marie, of Dun-sur-Auron (Cher.), presented a brief report on the family 
care of the insane in France, and distributed a report on the colony at Dun, from 
which it appears that from the time that the colonv was founded, at the end of 1892, 
up to the end of 1897, 673 patients have been aamitted. The admissions during 
the year 1897 were 175, and at the end of the year there were 555 patients in resi¬ 
dence. These figures alone show that the institution of family care at Dun has 
been a success. The colony had existed six years without an accident. The 
system was not alone economical, but was beneficial to the patients, who preferred 
it as being a more natural life than that of asylums. The town of Dun con¬ 
tains 6000 inhabitants, among whom the patients are boarded. The patients are by 
no means all dements, many being melancholics. There is a special hospital. 
The average cost is half of that in the Asylums of Department of Seine, whence 
the colony is fed. 

Aphasia in Relation to Testamentary Capacity. 

On July 28 th a conjoint meeting of the Sections of Psychology and State Medicine 
was held to consider this subject . 

A discussion on this subject was introduced by Sir William Gairdner, who, 
having indulged in a brief retrospect and shortly glanced at the anatomical bearings 
of the question, said that he was willing to concede that a man who had always 
been aphasic, who was deficient in anything that went to make the speech faculty, 
never could become a reasoning animal, or rise above the level of the dog, the 
elephant, or the horse. But when they came to the case of a man who by accident 
was lamed as regarded the mechanism of that particular faculty, having had all his. 

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reasoning powers beforehand, he was not willing to admit that he necessarily suffered 
any derogation from the higher faculties. The point there was how far did that 
laming of one faculty interfere with a man's capacity to make a will ? That ques¬ 
tion could not be answered in any general sense. 

Referring to a recent decision in a will case (not of an aphasic, however) tried 
before the Scottish Court of Session, Sir William Gairdner quoted Lord President 
Robertson’s ruling (premising that the Scotch law, founded on the old Roman 
civil law, was superior to the English judge-made law—a thing of shreds and 
patches). (Laughter.) The Lord President said this:—“He must remind them 
that they had not got to try the question whether in the general sense she was 
sane or insane. The question was much more narrow and limited. It had 
reference to this particular will—had she enough mind to understand it, and did she 
understand it ?—because there were many people in this world who had got what 
might be called a crack in them, and were really eccentric, and yet whose wills were 
perfectly good. Therefore in this case they had no abstract question to determine 
as to whether this woman was sane or insane, but they had to consider first the will 
and say whether she was able to understand it. They might think that it was too 
complicated for her, and if so, then they would find against the will. On the other 
hand, they might think, although they had heard a good deal of trash about 
the woman’s eccentricities”—(let them observe with what contempt he brushed 
aside the attempt to prove theoretical insanity)—“that still she had enough sense 
to make a will if it was a will that she could understand. ... It was to be 
observed in favour of the will that it was not very complicated, if they thought 
the woman really wanted it. They then would have to consider whether there was 
satisfactory evidence that her mind was applied to it. But in the meantime, as 
regards the woman herself, he dared to say that they had no doubt she was a 
person of rather low intelligence. She had not been well educated, and there was 
in the family a strain of eccentricity.’* He concluded that “ they were left a good 
deal in the dark as to what share this woman had in the making of the will at all. 
But it was for the jury to say whether this will was her own will. They must not 
break the will unless they really thought either that she was unfit to make it, that 
she had not sufficiency of mind to make it, or else that she was weak and was led 
into making it by other people.” That was very much in accordance with the way 
he himself put it. (Applause.) It threw the onus probandi entirely upon those who 
dispute its validity to show that the testator was not fully cognisant of what he was 
doing when he made it, or was misguided by interested parties. That was the 
position in law. How was it that the position was altered by aphasia? The fact 
of aphasia shifted the onus probandi upon those who considered the will genuine. 
It made a difficulty in the way of the testator giving expression to his true desires 
and true will, and those who supported the will had to prove that that difficulty 
was successfully overcome. He held that a person completely aphasic had, 
as regarded his inner mind, the capacity to make a will quite sufficient to meet 
these legal conditions in all probability. He exemplified the case of Pasteur, 
who for the last few years of his life suffered from left hemiplegia. Was there 
the least reason to suppose that if, instead of being on the right side of his brain 
that lesion had been on the left side, Pasteur would not have been able to form 
that will in his own mind, would not have been able to make a valid will, providing 
that he could have positively impressed everyone that that was his will P He held 
that there was no doubt whatever that his testamentary capacity might have been 
totally unaffected, except that which they might regard as outward mechanism. The 
difficulty they placed in the way was an additional obstacle to be got over, and the 
multiplication of these obstacles might incidentally preclude the possibility of 
giving effect to the intention, which nevertheless might have been quite clear in 
the testator’s mind if he could only have got it out. The question of whether an 
aphasic could make a will was a question of detail entirely. It was a question 
that must be submitted to a jury upon the individual case. The principle was, did 
the man know what he wanted, did he form a clear conception of what he wanted, 
and did he succeed in giving effect to that conception ? 

Dr. William Elder said that every case of aphasia was mentally and intellectu¬ 
ally on a lower level than the patient was before he was affected. Betweeh that 
condition, however, of slight degradation of the mental and intellectual altitude of 
an individual and the other condition of actual mental incapacity there was a vast 


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difference, and there were many steps, so that it must necessarily always be a diffi¬ 
cult question to answer where sanity ended and insanity began, where testamentary 
capacity ended and incapacity began. It must be laid down as a general principle 
that no one could make a will who did not possess the power of understanding and 
producing language of some sort. It would not be held to be a will if a person 
simply indicated by signs before he died that he wanted such and such a thing to be 
done, nor would it be held to be a will if a person gave directions by word of mouth. 
A person must be capable of understanding language, so that he knew either what 
he said or what was read to him. That implied that he could hear and understand 
words if he could not read or understand pantomimic language; but if he could read 
and understand what he read, then it was not necessary for him to hear or under¬ 
stand pantomimic language. Given that a person understood what was in a docu¬ 
ment, it was not necessary that he should be able to speak in order that he might 
execute a testamentary deed. He might indicate what he wished by means of 
writing, or by pantomime, or in other ways. A complete case of auditory aphasia, 
which implied word deafness and word blindness, would be incapable of making a 
will, because, not being able to understand any form of language, he would, in all 
probability, not be able to communicate his wishes by producing any form of lan¬ 
guage. From a consideration of the whole subject he had come to the conclusion 
that some forms of aphasia might render a patient incapable of will-making, such as 
auditory aphasia, pictorial word blindness, pictorial motor aphasia, ana graphic 
aphasia, although he was not necessarily mentally incapable. 

Dr. Clouston (Edinburgh) said there were two points which he insisted every 
man must attend to. The first was the test ijuestion whether it was the will of the 
individual or whether it had been suggested to him. The second was that in 
making the will of any aphasic patient it was the duty of every medical man to 
put the contrary case. A man had left, say, ^100 to his wife and jfioo to his 
daughter—to A and B. They were bound to ask him if it was for B and C or for 
D and E that he intended the money. No will of an aphasic could be a legal and 
proper will unless the contrary case had been thus put, because an aphasic would 
assent to anything if put to him in a certain way. 

Insanity in Criminal Cases. 

{Also considered by the Conjoint Meeting.) 

Dr. Mercier opened a discussion on the Plea of Insanity in Criminal Cases. 
He asked the assent of the meeting to three propositions. In the first place he 
asked them to say that no insane person should for any act be punished with the 
same severity as a sane person would be punished for the same act. Every 
institution for the insane was conducted in accordance with that principle. The 
second proposition was that there was for every insane person a certain sphere of 
conduct for which he ought to be entirely immune from punishment. • Every insane 
person might commit certain deeds for which he should not be punished at all— 
misdeeds which, if they were done by sane persons would be rightly punishable, 
but which in the case of insane persons it would be clearly and manifestly wrong to 
punish at all. His third proposition was that very few indeed of the insane were 
wholly irresponsible. He meant by that that there were very few indeed of the 
insane who ought never to be punished. With a full appreciation and expectation 
of the misunderstanding and obloquy and odium he would incur by the statement, 
he affirmed that for very many of their wrong acts the majority of lunatics ought 
to receive some punishment; further, he affirmed that explicitly or implicitly that 
was the opinion of every practitioner who had experience of the insane, and, 
furthermore, he affirmed that punishment of the insane in some form or other was 
in practice in every institution for lunatics. Let them clear their minds of cant in 
this matter. Who was there among them who, if a patient on parole came in 
drunk, would not refuse him his parole next time, and time after time when he 
applied for it P Who was there that, when a woman had been fighting or smashing, 
would not forbid her to attend the weekly dance ? Who was there among them 
that would not stop the tobacco of a man who was discovered pilfering or 
bullying? It might perhaps be denied on other grounds that this was punishment. 
It might be said that a woman who was so violently maniacal as to be fighting and 
smashing was unfit to attend a dance, and was forbidden for that reason, and not 

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for punishment. But he declared that in a patient who had 4 >een smashing or 
tearing up her clothes not in an excess of acute mania, but in an outbreak of temper, 
she would be excluded from the dance, not because she u r as unfit to be present, but 
as a punishment. They relied upon the temporary withdrawal of privileges to act 
as a check in preventing abuse in future; that was to say they withdrew it as a 
punishment. 

The practical importance of these propositions with regard to the plea of insanity 
was that while there were some cases in which they might rightly ask the court to 
refrain altogether from punishing the criminal, there were many more cases in 
which they could not justly demand such immunity, but in which they could fairly 
argue that the criminal was responsible to some extent, but was not wholly 
responsible, and that therefore, while he ought to be punished, he ought not to hie 
punished with the same severity as an ordinary offender. While it was common 
for a crime to be committed under the promptings of delusion, it was extremely 
rare for the delusion to be of such a character that if it represented the actual facts 
of the case it would completely justify the act. He exemplified the case of Prince, 
the murderer of Mr. Terriss. 

In conclusion, the speaker laid down the following propositions: 

(i) All lunatics should be partially immune for all their misdeeds; (2) Every 
lunatic should be wholly immune for certain misdeeds ; (3) Very few lunatics 
should be wholly immune for all misdeeds—corollary—the plea of insanity, if 
established, did not necessarily involve the total immunity of the accused from 
punishment; it did necessarily involve his partial immunity ; and (4) That in order 
to establish the plea it was necessary to prove the existence in the accused of one 
or more of the following mental conditions :— (a) exonerating delusion ; (A) such 
confusion of mind that the accused was incapable of appreciating in their true 
relations the circumstances under which the act was committed or the consequences 
of his act; ( c) extreme inadequacy of motive ; (d> extreme imprudence in the act ; 
and (e) the non-concurrence in the act of the volitional self. 


QUEBEC MEDICO-PSYCHOLOGICAL SOCIETY. 

The physicians attached to the asylums of the Province of Quebec—Arthur 
Vallde, medical superintendent of the Quebec Lunatic Asylum, T. J. W. Burgess, 
medical superintendent of the Protestant Hospital for the Insane, E. J. Bourque, 
physician-in-chief, George Villeneuve, medical superintendent, F. E. Devlin, assist¬ 
ant superintendent, F. X. Perreault, A. J. Prieur, C. Laviolette, and E. P. Chagnon, 
assistant physicians of the St. Jean de Dieu Lunatic Asylum, Longue-Pointe,— 
held a preliminary meeting on the 16th February last, at Longue-Pointe, for the 
purpose of organising themselves into a society for the advancement of the 
specialty. 

It was resolved that the association should be known as the “ Quebec Medico- 
Psychological Society,” and that meetings should be held in turn at the different 
asylums of the province. The following officers were elected for the years 1898*9: 

President .—Arthur Valine, M.D., medical superintendent of the Quebec Lunatic 
Asylum. Vice-President.— T. J. W. Burgess, M.D., medical superintendent of the 
Protestant Hospital for the Insane, Verdun. Secretary. —E. r. Chagnon, M.D., 
assistant physician of the St. Jean de Dieu Asylum, Longue-Pointe. 

Pursuant to this organisation the first meeting of the Society took place at St. 
Jean de Dieu Asylum, on July 14th, 1898, Dr. ValUe, president, in the chair. 

Election of New Members. 

A. Marois, assistant superintendent, A. Belanger and C. S. Roy, assistant 
physicians to Quebec Asylum, L. J. O. Sirois, physician to St. Ferdinand d'Halifax 
Asylum, and J. V. Anglin, assistant physician to the Protestant Hospital for the 
Insane, Verdun, were elected members of the Association. 


Resolutions. 


Mr. Villeneuve moved that Honourable Mr. J. E. Robidoux be elected Patror. 
of the Society. Mr. Burgess seconded the motion. Carried unanimously. 


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Moved and unanimously voted: 

1. That Mr. Gustave Lamothe, C.M., be elected as legal adviser of the Society. 

2. That the Inspectors of Insane Asylums be invited to form part of the 
Association. 

3. That Messrs. Villeneuve and Chagnon be chosen to draw the rules and 
bye-laws of the Society. 

4. That the members of the Society have learned with grief the death of the 
lamented Dr. L. M. A. Noel, medical superintendent of St. Ferdinand d’Halifax 
Asylum, and member of the Quebec Medico-Psychological Society, and that they 
express to Mrs. Noel their sympathies and their most sincere condolence in her 
great misfortune. 

5. That the members of the Society present to the Reverend Sister Superioress 
of St. Jean de Dieu Asylum their best thanks for her hospitality towards the 
meeting. 

6. That the second meeting take place next October, at the Protestant Hospital 
for the Insane, Verdun. 

Papers. 

Medical Certificates. 

Dr. Villeneuve regretted that most of the medical certificates on admission of 
patients are far from being equal to the importance of the measure which they 
authorise. If a person be in a mental condition required by law to be admitted into 
an asylum, this fact is to be established by a medical certificate made out according 
to formulas B and C, signed by the same doctor and certified under oath. The 
administrative decision of the medical superintendent and the proceedings taken 
rest on the statements and facts so consigned. He is thereby justified in keeping 
the patient under observation for no definite period. The insufficiency of medical 
certificates, the want of care with which they are delivered, the futility of the motives 
which they contain, the uncontrolled facility with which doctors accept the infor¬ 
mation furnished by interested friends, are all causes of worry. To his knowledge 
people have tried to secure admission for incorrigible children, unmanageable deaf 
mutes, troublesome dotards, cases in the last stage of chronic affections, such as 
locomotor ataxia. Cases of typhoid fever, meningitis, encephalitis have been 
brought to the asylum as suitable for treatment there. The law is very clear in 
stating that the medical certificate must state the mental condition of the patient. 
It must enumerate the symptoms and facts of insanity personally observed ; it must 
state the reason why the patient should be admitted into the asylum, either for 
treatment or as a matter of public order or security. Besides the certainty of the 
proof of insanity the medical superintendent must find in it the above-mentioned 
reasons to justify himself in admitting the patient. Therefore this certificate must 
contain facts and not vague presumptions, especially when the indications for 
admission are not exclusively deduced from the particular from of insanity form which 
the patient is suffering. 

There are circumstances where it may be necessary to have recourse to a magis¬ 
trate—when the certifying doctor is obliged to rely for the most part on statements 
made by friends of the patient, when investigations are necessary to establish the 
veracity of these statements, or when difficulties arise as to certain classes of 
patients such as the persecuted. In these cases it is well to proceed before a 
magistrate, according to the law concerning dangerous lunatics, and to take the 
testimonies of the persons who have witnessed the insane actions of the patient; after 
that a warrant is issued bv the magistrate, who orders the patient to be sent to an 
asylum. Dr. Villeneuve Delieves that the medical certificate ought to be divided in 
two distinct parts, as in England and the State of New York. In the first part the 
doctor should state the symptoms of insanity which he has himself observed; in 
the second he should state the facts which he has known from other persons, at the 
same time naming these different persons. 


Rubeoliform Eruptions produced bv Sulphonal. 

Dr. Burgess reported a case which, after the use of sulphonal, presented an 
eruption closely resembling that of measles. 


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A Case of Sitiophobia cured by Sulphonal. 

Dr. A. Vall^e reported a case of sitiophobia in which sulphonal seems to have 
given excellent results. A. B—, aged 26, admitted to the Quebec Asylum in May, 
1893, suffering from melancholia with stupor. She was in a complete state of 
mutism and refused all nourishment. The stomach-tube was required for many 
months. The patient remained in stupor, motionless, head dropping on the chest, 
indifferent to everything around her, and absorbed in her delusional conceptions. 
In spite of tonics, stimulants, electricity, hydrotherapy, and generous diet, we could 
not obtain the least improvement. She continued speechless, offered more and 
more resistance when fed artificially. The organic functions were greatly deficient, 
nutrition was bad, the extremities were cold and cyanosed. She lost flesh rapidly 
and became dirty in her habits. The prognosis was bad. Dr. Vallde said, 
I read in the Journal of Mental Science (October, 1893) a note by Dr. 
Brough, on the use of sulphonal in sitiophobia, and decided to try the remedy on 
A. B—. On the 10th day of November, at 8 p.m., I gave her 40 grains of sulphonal. 
She slept very well, and on waking next morning made signs to her nurse indicating 
that she wanted something to eat. Food was brought immediately, and was eaten 
greedily. I continued to give sulphonal for a few days; the appetite remained 
good, and the patient continued to eat with relish. Now her mental condition is 
not much better, but she is a little brighter, she talks more readily, and her general 
health is excellent. 


Foreign Body of the Intestine; Death; Autopsy. 


Dr. Burgess reported this case.—R. S—, aged 32, a case of long-standing demen¬ 
tia. July 3rd, 1898.—A slight attack of diarrhoea. Little or no pain, no constitutional 
disturbance. Treated with lead and opium pills, which checked diarrhoea. July 
7th.—Complained of slight pain in the abdomen; no signs of tenderness and no 
constitutional symptoms. Bowels loose again. July 9th.—Still complains of pain 
in abdomen ; slight tenderness on pressure and some tympanites. Vomited several 
times during day, but no diarrhoea. Pulse slightly increased, but full and soft; a 
rise of one degree in temperature. Appendicitis suspected. July 10th.—Did not 
sleep last night, in spite of a full dose of morphia, and is much worse this morning. 
Constant vomiting, with signs of failure. Pulse and temperature both much 
increased, and a good deal of tenderness over abdomen, especially on right 
side. Dr. Armstrong called in consultation, but decided that it was too late for 
operative interference. Patient died at 2.40 p.m. 

Autopsy .—Body that of a young man dead twenty hours. Post-mortem rigidity 
complete. Skin sallow. Post-mortem lividity well marked on back, sides, and 
thighs. Signs of commencing decomposition in front of abdomen, which is dis¬ 
tended. Subcutaneous fat absent; muscles of a dark red colour. Abdomen dis¬ 
tended with a turbid brownish fluid having a faecal odour. On the left side, about 
the level of the umbilicus, is a small,jblack, gangrenous area, in which projects a 
broken piece of needle. Evidence of intense general peritonitis. 

In the great omentum another fragment of needle is discovered. On separating 
the coils of the collapsed portion of intestine, a wire (hair-pin) is found penetrating 
the mesentery about two inches from the edge of the bowel, penetrating also one of 
the coils of the ileum. This wire passes backward, catching up on its passage a 
second coil of ileum, and is then embedded in the quadratus lumborum muscle of 
the left side. On removal of the intestines they are found normal until about three 
feet from the ileo-cxcal valve, where the intestine becomes much dilated; the walls 
and mesentery are much thickened and inflamed. This condition persists for about 
eighteen inches to a point where constriction has occurred through the mesentery of 
the intestine. On opening up the affected section about eighteen inches from the 
ileo-caecal valve there are found three or four sharply cut lacerations of the intestine, 
as if from a sharp-pointed instrument. About this point perforation had occurred. 
At every place where the wire came in contact with the tissues is traced a brownish- 
black discoloration. The appendix was inflamed externally, but practically normal 
within. Stomach normal. Kidneys normal. Spleen small, capsule wrinkled, very 
flabby; on section pale and firm; weight two ounces. Liver congested, with cloudy 
swelling; lobules indistinct. Heart .—Right side contains soft, reddish clot; left 


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1899.] 

side is contracted and empty; all the valves normal. Lungs. —Right lung free from 
adhesions, somewhat congested; crepitant throughout on section; weight nineteen 
ounces. Left lung adherent by lower lobe posteriorly and to diaphragm; weight 
sixteen ounces. Bronchi in both lungs normal. 

The hair-pin had probably been swallowed some time previously, as there was no 
trace of irritation in the stomach. 

Influence of Traumatism on Mental Affections. 

Dr. A. Vall4e reports the following case:—L. T—, aet. 62, admitted to the 
Quebec Asylum 12th March, 1894, suffering for the last five months from a severe 
attack of melancholia, brought on by pecuniary troubles and alcoholic excesses. 
Believing himself to be damned for ninety-nine years, he kept perfect silence. 
Nothing could distract him for a moment, and he opposed a passive resistance to 
all our endeavours. His general health gradually gave way under the influence of 
melancholia, complicated by insomnia and sitiophobia, and he was sent to the 
infirmary. 

May 3rd.—I was called to extract a foreign body which he had thrust into his eye. 
He was sitting on his bed quite silent. A black spot was noticed at the internal 
angle of the right eye. It was the head of a nail four inches long, and was at once 
extracted. Alarming symptoms soon appeared: face very pale, extremities cold, 
pulse filiform, left arm and leg paralysed. 

May 4th.—He rallied a little, but the hemiplegia continued. 

May 5th.—Partial convulsions set in over the face, lips, neck, and left arm. They 
lasted about twenty-four hours. 

May 8th.—Hemiplegia disappearing; mental state improving. 

After three or four days ail the nervous symptoms have disappeared except a 
divergent strabismus of the right eye, which lasted about fifteen days. The general 
health and the mental condition continued to improve gradually till, at the end of 
May, he was able to walk round the asylum by himself. His memory was perfectly 
good, but he does not know why he thrust the nail in his eye. On the 15th of July 
he left the asylum perfectly recovered. 

Another case where traumatism hastened recovery occurred here a few years ago. 

O. R—, aet. 25, admitted suffering from a violent attack of acute mania. A few 
weeks after his admission he quarrelled with another patient, and was bitten very 
severely on the thumb. Intense nervous tremors set in, and lasted for an hour. 
Thereafter O. R— became conscious, made a rapid recovery, and was discharged in 
a few days. 


RECENT MEDICO-LEGAL CASES. 


Reported by Dr. Mercier. 

{The editors request that members will oblige by sending full newspaper reports of 
all cases of interest as published by the local press at the time of the assizes.] 


Reg. v. Bryson . 


John Bryson, an elderly man, was indicted for the murder of a woman with 
several aliases. The murder was a peculiarly brutal one, the woman's head being 
battered into a shapeless mass, both eyes destroyed, and the face rendered unrecog¬ 
nisable. No evidence of provocation is reported. The prisoner had been drinking 
a good deal just before the murder, and when arrested immediately after was much 
the worse for drink. It was proved that he had had a sunstroke, and had narrowly 
escaped being killed by lightning, and that since these experiences he had been 
subject, especially when in drink, to outbreaks of unprovoked violence, of which 
he appeared afterwards to have no recollection. Several such outbreaks were 
described by witnesses. The prisoner, by advice of his counsel, pleaded guilty of 
culpable homicide. Sentence was delayed until the afternoon, when the judge 
stated that after consultation with his colleague he had been able to decide to treat 
the prisoner in a comparatively lenient manner.—Ten years’ penal servitude.—(The 
Lord Justice’s Clerk.)— Scotsman , August 31st. 

A fresh instance of the growing practice of considering the mental condition of 
the convict in awarding punishment. The prisoner was allowed to plead guilty of 


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[Jan., 


homicide merely, and sentence was mitigated in consideration of the state of 
his mind. 

Reg. v. Truett. 

Charles Truett, 60, labourer, was indicted for the murder of his sister-in-law. 
Prisoner walked into the home of the deceased and stabbed her with a long knife, 
inflicting a wound of which she died. Shortly after he said, “ Revenge is sweet. I 
don’t care if I hang, as long as she dies.” It was proved that the prisoner had long 
had an erroneous belief that his father’s property had been unequally divided, ana 
that the deceased was responsible for the unequal division. At the police station he 
was noticed to be very strange in his manner, and it was shown by the prosecution 
that he had long been regarded as not responsible for his actions.—Guilty, but 
insane.—Central Criminal Court, July 28th (Mr. Justice Lawrence).— Times. 
July 29th. 

This case illustrates once more several very common occurrences. The evidence 
showed clearly that the prisoner knew the nature and quality of his act, and knew 
that it was wrong. Yet he was found insane. Evidence of insanity was furnished 
by the prosecution. And it is a fresh instance of the commission of a serious crime 
by a man who had long been known to be insane, and who ought not to have been 
at large. 

Reg. v. Copeland . 

Prisoner, a woman set. 28, was found lying in three feet of water with a child 
under each arm. She was restored, but the children were dead. On being rescued 
she said that “ she had been put about, and didn’t know what to do with herself. 
She had had no sleep all night, she was very ill, and her husband was angry with 
her.” It was proved that she was much weakened by illness and recent operations, 
and it was suggested that her mind had thereby become affected.—Guilty, but 
insane.—Stafford Assizes, July 26th (Mr. Justice Channell).— Times, July 27th. 

There was no evidence of insanity except the act itself and the inadequacy of the 
motive; yet an unquestionably just verdict was given. 


Reg. v. Viney . 


William Viney, 72, labourer, was indicted for the murder of three of his children 
and the attempted murder of a fourth. Prisoner, who had been at one time well 
off, but had sunk to the position of a hawker, and who had been deserted by his 
wife, took his five children to Leyton marshes, and there cut the throats of four of 
them, killing three and seriouslv injuring the fourth, while the fifth ran away. It 
was proved that some time before, the prisoner had been considered unsound in 
mind. Dr. Scott said that the prisoner was of weak mind, but he could not certify 
him as insane at the present time. The prisoner had told him that a power of 
darkness came over him, and he thought it right to kill the children, so that they 
might go to a better world. The jury found a verdict of guilty, but said that 
there were extenuating circumstances, and strongly recommended the prisoner to 
mercy.—Central Criminal Court, September 15th (Mr. Justice Darling).— Times, 
September 16th. 

A case very similar to that of Copeland (supra), but with decidedly stronger 
evidence of insanity. Yet Copeland was found insane, and Viney was not. 
Clearly one of those verdicts was wrong. Are we then to blame the lawP 
Scarcely. Under the same law that condemned Viney, Copeland was found 
insane. It was not the law, therefore, that required the condemnation of Viney. 
The discrepancy is to be found in the fact that the judges were different, the 
counsel different, and the juries different. So long as the personal element in 
trials remains, so long will there be a discrepancy in verdicts. But in spite of the 
differences in the verdicts, the fate of the convicts will be the same, and thus the 
personal variation is rectified. 

Reg. v. J. A. Campbell. 


Prisoner was the Superintendent of the Garlands Asylum, and was charged with 
the offence, under the Lunacy Act, 1890, of having intercourse or attempting 
to have intercourse with a female patient under his care. The facts were un¬ 
disputed, and the plea of insanity was raised. It was proved that the prisoner had 
for years been habitually intoxicated, and that for months past he had rendered 


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1899.] 

himself conspicuous by habits of absurd braggadocio, which led those with whom 
he associated to regard him as insane, and as subject to delusions of grandeur. 
The offence was committed with scarcely any precautions in the way of conceal¬ 
ment, and was of a nature that, considering the position and the age of the 
prisoner, of itself suggested insanity. On the other hand, it was proved that 
even up to the time of the offence the prisoner was capable of transacting 
difficult business in a thoroughly efficient manner.—Guilty, but insane.—Carlisle 
Assizes, November 4th (Mr. Justice Phillimore ).—East Cumberland News, 
November 5th. 


Reg. v. Yeo. 

Henry Yeo was indicted for publishing libels concerning Dr. Bevan Lewis, 
Superintendent of the West Riding Asylum. The prisoner was the editor of a 
weekly paper called the Spy, published at Manchester, and in 1896, while under¬ 
going a sentence of twelve months' imprisonment for libel, he was transferred from 
prison to the West Riding Asylum as a criminal lunatic. He appears to have 
been released at the expiration of his sentence, and subsequently published in his 
paper a series of articles containing gross libels upon Dr. Bevan Lewis. The 
prisoner defended himself, and in his address to the jury he alleged that Dr. Lewis, 
by means of some electrical apparatus or patent process, could tell what he was 
doing wherever he was. He appealed to the judge to inquire into his persecution, 
and to order an expert to examine the asylum and discover the apparatus by which 
the persecution had been effected. The jury found the prisoner guilty, and he was 
sentenced to twelve months’ imprisonment. The prisoner’s wife, who had assisted 
in publishing the libels, pleaded guilty to this offence, and in sentencing her the 
judge said that as her husband was subject to delusions, and could scarcely be held 
responsible for what he did, she had done very wrong to assist him.—Yorkshire 
Assizes, August 1st (Mr. Justice Grantham).— Times, August 2 nd. 

Reg. v. Anderson. 

James Anderson, 45, ship carpenter, was indicted for the murder of his wife. 
Prisoner W'as of intemperate habits, and often quarrelled with his wife. The 
evening of the murder the two appeared to be on exceptionally amicable terms, but 
at about 8 p.m. the neighbours heard a disturbance, and it was found that the 
prisoner had killed his wife by cutting her throat, and had then inflicted a severe 
wound upon his own. It appears that he believed that his wife exerted a “ spell 
power ” over him, and could make him, even when he was away from her, do deeds 
that he would have shrunk from; that she tried to poison him with beetroot and 
onions; that others besides his wife were his enemies, and were trying to thwart 
him in every way, and were conspiring against him; and that for the last twenty 
years his relatives have regarded him as insane. He was found unfit to plead, and 
ordered to be detained during her Majesty’s pleasure.—(LordTrayner).— Scotsman, 
September 17th. 


AFTER-CARE ASSOCIATION. 

The annual meeting will be held on Monday, February 6th, 1899, at 72, Grosvenor 
Street, W., the residence of Sir Samuel Wilks, President of the Royal College 
of Physicians, who will preside. The past year has been, we are informed, by far 
the most successful one in the annals of the Association, both in the number of 
cases assisted and in the amount of the subscriptions. Unfortunately the subscription 
of £so> promised by Mr. Mocatta if ^1000 were raised during the year, cannot be 
claimed. 

The active assistance of the Medical Superintendents of Asylums is earnestly 
sought: many have long given it the most energetic support, but it is hoped that 
the increased means and experience of the Association will enable it to deal even 
more satisfactorily with the cases in future entrusted to it than it has done in the 
past. 


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NOTES AND NEWS. 


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2 14 


THE JOURNAL. 

The Editors have attempted in the present issue to improve the form, type, and 
outward appearance of the Journal as far as this was possible without adding 
materially to the cost of production. The alterations will speak for themselves, 
and the Editors trust that members of the Association, remembering the above 
limitation, will find the changes improvements, rendering the Journal more 
worthy of the important interests which it now represents. 

The Editors enclose an appeal to the Members of the Association to aid them in 
increasing the monetary prosperity of the Journal, in which, they believe, much 
might be done by united effort. 


CRAIG COLONY PRIZE FOR ORIGINAL RESEARCH IN 
EPILEPSY. 

The President of the Board of Managers of Craig Colony offers a prize of $100 
for the best contribution to the pathology and treatment of epilepsy, originality 
being the main condition. The prize is open to universal competition, but all manu¬ 
scripts must be submitted in English. All papers will be examined by a Com¬ 
mittee to consist of three members of the New York Neurological Society, and 
the award will be made at the annual meeting of the Board of Managers of Craig 
Colony, October 10th, 1899. 

Each essay must be accompanied by a sealed envelope containing the name and 
address of the author, and bearing on the outside the motto or device which is 
inscribed upon the essay. The successful essay becomes the property of the Craig 
Colony for publication in its Annual Medical Report. 

Manuscripts should be sent to Dr. Frederick Peterson, 4 West 50th Street, New 
York City, on or before September 1st, 1899. 


RESIGNATION. 

Dr. Symes Saunders has retired from the office of medical superintendent to the 
Devon County Asylum, having recently entered on the fortieth year of his 
service in that institution. The venerable chairman, Mr. Saunders, wno has been 
connected with the Devon County Asylum ever since it was opened, in the course 
of an appreciative speech on the occasion of Dr. Saunders’ resignation, reviewed the 
financial history of the institution, and moved that a pension of ^742 IOS - P* r 
annum be granted. This sum had been arrived at on a calculation of two thirds 
of the salary and emoluments. We congratulate Dr. Saunders on the finding of 
the County Council, and express the hope that he will enjoy his retirement after so 
many years of work. It may be noted that an attempt to arrive at an understanding 
with his successor, to the effect that a pension would not necessarily follow on his 
service, was ruled out of order by the chairman of the County Council. 


PRESENTATIONS. 

At the Wameford Asylum, Oxford, Dr. Neil had recently the pleasant duty of 
presenting to Mr. Matthews, the chief attendant, who has captained the cricket 
club for thirty-seven years, a handsome clock; and to Dr. Goldie-Scot, who has 
served as assistant medical officer for the past year, a marble timepiece and other 
souvenirs from the patients. We record these incidents with pleasure. 


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I 899.] NOTES AND NEWS. 21 5 

THE WELFARE OF THE FEEBLE-MINDED. 

The Duchess of Sutherland, who, as President of the National Association for 
Promoting the Welfare of the Feeble-minded, presided at a special meeting of the 
Association held on June i ith, at Stafford House, London, put the case for generous 
public support of the objects of the Association with clearness and force. The 
physically and mentally defective child, she pointed out, has every chance, under 
existing conditions, of becoming part of the “ scum ” of our population, which is 
just another way of saying that many vagabond and criminal adults were in childhood 
mentally defective children, who might have been trained for better things. “ They 
knew,” her Grace said, ” that in many of our asylums to-day there were men and 
women whom Mr. Asquith spoke of on the second reading of the Prisons Bill as 
persons of morbid and erratic nervous systems, to whom it was difficult to apply 
anything like the ordinary canons of moral responsibility.” Such persons, 
however, are not only to be found in asylums, they are also in prisons, in work- 
houses, and, when not of vicious habits, they float about as part of the starving 
and struggling flotsam and jetsam of the industrial life of our large cities. When 
so high an authority as Mr. Asquith so clearly, and with strict accuracy as to facts, 
expresses the opinion that a considerable number of prisoners are persons of 
morbid and erratic nervous systems, to whom it is difficult to apply the ordinary 
canons of moral responsibility, there seems good ground for the Duchess’s remark 
that the Association is doing in a measure a work which the State should do for 
itself. But the State takes no account of the roads along which come the lunatic, 
the pauper, and the criminal, although they are tolerably well defined; and until the 
State takes the reasonable view of its obligations in this connection in at least 
making some attempt to prevent that which may be preventable, such associations 
as this have excellent work to do. Her Grace remarked truly that fifty years ago there 
would have been no hope for those deficients. It would be interesting to consider 
whether the problem of the deficient member of society was quite the same fifty 
years ago as it is to-day. Pauperism has decreased, lunacy has increased, and a 
certain change has come over the criminal population during the last fifty years. 
The violent, insubordinate prisoner of the last generation of criminals has been 
replaced by a type of criminal more amenable to prison discipline. Concurrently 
with this change, no doubt, there has been considerable amelioration of the 
disciplinary methods adopted towards criminals, but whether post hoc ergo propter 
hoc is still an open question. The social changes that underlie those facts have an 
important bearing upon the whole class of questions which have as their common 
feature the element of deficiency. Every step towards organised efficiency in trade, 
commerce, education, and society generally, means that a new test has been created 
for the discovery and elimination of the weak and the unfit. That truth is not 
always present to the minds of those who advocate changes in our commercial, 
industrial, and social arrangements; it explains, however, some of the unhappy 
consequences that accompany economic and social progress. Fortunately, human 
nature is equal to the new difficulties!; and though the progress of the last fifty 
years has brought with it the problem of the deficient members of society who 
cannot adjust themselves to their social environment, there has arisen a public 
spirit animating the more fortunate members of society to do their duty towards 
their less fortunate brethren. Everywhere there is evidence that this is so, and 
that at least the question of the care and education of mentally defective children 
is receiving earnest practical attention. London, Manchester, Birmingham, 
Glasgow, and other large centres of population are moving in the direction of 
providing special facilities for the care and training of such children. Whether 
the instruction of defective children requires to be carried on in specially equipped 
schools, separate as regards buildings from schools in which the ordinary standard 
work is carried on, is a question for the school boards to consider. The obvious 
objections to that method are the cost of separate buildings, and being limited 
in number, the distance at which the schools would be placed from the homes of 
the majority of the children. 

But we would encourage school boards to try the experiment of having separate 
class-rooms in the ordinary schools rather than separate buildings; and we would 
say further, do not attempt too much in the way of purely educational training, 
because the aptitudes of mentally defective children are usually industrial and 

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[Jan., 


musical rather than in the region of memory and reasoning. The practical diffi¬ 
culty of separating the imbecile child, who should be placed in an imbecile 
institution, from the mentally defective child, who can be taught in a special class 
and kept at home, is one which the experience of a medical man, specially qualified 
for the work, can best determine. Circumstances unconnected with the state of 
the child’s mind may occasionally determine the question for the one form of 
training or the other. But after all has been done for those children that school 
boards can do, there will still be work for such associations as that for whose funds 
the Duchess of Sutherland pleads. The officials who have to administer the Poor 
Law, the Criminal Laws, and the Lunacy Laws ought to welcome the help of 
this and kindred associations in promoting the welfare of many adult deficients 
who come their way, and for whose care when out of their hands there exists no 
provision. 

It is obvious that the ladies and gentlemen who are trying to awaken 
public interest in this matter are not only doing a needful and praiseworthy thing, 
but they are tackling a subject of wider relations than some of them may appre¬ 
ciate. Failure to appreciate their proper functions may lead them to adopt 
methods and encourage schemes which may overlap, and perhaps threaten the 
financial stability of existing institutions for the care of imbeciles and idiots. 
Illustration of this is to be found in the fact that the principal and secretary of the 
Royal Albert Asylum, Lancaster, has found it necessary in the interests of that 
institution to write a letter to the editor of the Manchester Guardian in order to 
make clear to the benevolent public of Manchester, who have been asked to give 
^20,000 for the erection of two institutions in Manchester for the housing and 
training of feeble-minded children, that the Royal Albert Asylum exists “ for the 
care, education, and training of idiotic, imbecile, and weak-minded children and 
young persons." There is real danger that the public may fail to apprehend 
the difference between the existing imbecile institutions and the proposed new 
provision for backward and feeble-minded children, with the result that public 
support may be given indifferently to both classes of institutions, to the financial 
injury of both. It is due to the existing institutions that those who are promoting 
the new movement should clearly define the objects and limits of their scheme 
before setting up establishments and appealing for public support. The eloquent 
and suggestive speeches of the Duchess of Sutherland and Miss Dendy, made at a 
meeting at Manchester in support of the scheme for the building of two institutions 
in that city, show that the line of demarcation between their scheme and the work 
of imbecile institutions is quite clear and distinct to their minds. It should 
therefore be easy for them to make it clear to the public, and it is their duty to do 
so, because it may be assumed that the sympathy of their audience was gained by 
the thought being present to their minds that help was asked for imbeciles. We 
say so because we are not at all sure that public sympathy is ready waiting an 
outlet towards feeble-minded thieves, loafers, et hoc genus ; and it is certainly not 
clear that the responsible authorities, whose business it is to punish criminals and 
prevent crime, are ready to back up the efforts of this new movement. The first 
task to be undertaken is educative; that is to say, educative of public opinion 
regarding the true nature of what may be called social inefficiency as a sign or 
symptom of some forms of mental weakness. How far it will be possible to apply 
the doctrines of degeneracy in a practical scheme which will meet the requirements 
of the case, and at the same time satisfy the juridical point of view, is the problem 
to be solved. Prevention, which is both easier and better than cure in most cases, 
is the ideal here; but it must not be forgotten that the majority of lifelong 
criminals begin their career of crime in youth, without, in many cases, manifesting 
signs of deficiency in childhood, and if this work is to be done well it must include 
the care of the juvenile and adolescent offender. 

We welcome the scheme as an attempt to deal practically with a complicated 
and difficult problem that has been long enough in the region of mere discussion, 
and we hope that its promoters will successfully keep clear of the difficulties that 
lie in its way even at the threshold. 


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1899] 


NOTES AND NEWS. 


217 


A “ COLONY ” FOR EPILEPTICS AND IMBECILES IN 
LANCASHIRE. 

The Joint Asylum Committee of the Manchester and Chorlton Boards of 
Guardians have applied to the Local Government Board for sanction to the 
purchase of an estate near Chorley, known as the Anderton Hall estate, for the 
purpose of providing an asylum on the “colony” system for imbeciles and 
epileptics. 

The committee recently appointed two of their number, Dr. Rhodes and Mr. 
Alderman McDougall, a deputation to visit Belgium, France, and Germany. These 
two gentlemen visited a large number of asylums, and had come to the conclusion, 
reinforced by the findings of their committee, that an asylum on the “colony” 
system was required. The Anderton Hall estate was found to be the most suitable 
for this purpose. It is pleasantly situated on a slope opposite Rivington Pike, 
above the Rivington reservoir. It contains 237 acres, could be purchased for 
^19,000, and was not more than twenty miles from the two unions; two railway 
stations were easily accessible from it. 

The committee proposed that the asylum should be occupied by epileptics and 
imbeciles of the harmless class, of whom they had at present about 600 in the 
workhouses alone. The asylum would consist of a number of villas put up on 
different parts of the estate, and they would be placed away from the Rivington 
reservoir, so that if there were any surface drainage it would run in an opposite 
direction. Further, the committee proposed to lay down an intercepting sewer 
which would absolutely stop any possibility of contamination of the reservoir water. 


SEWAGE DISPOSAL. 

The coal filter briefly alluded to in the October number of the Journal was 
first brought into prominence by Mr. Joseph Garfield, A.M.I.C.E., engineer of the 
Wolverhampton Sewage Outfall Works, who recommends that it should be con¬ 
structed as follows: 

The effluent drain-pipes are covered with a 6-inch layer of coal, about half-inch 
cubes in size. This layer is blinded with a little quarter-inch cube coal, above this 
comes a layer of twelve inches of coal, one-eighth inch cubes, and next a layer, 
three feet deep, of one-sixteenth cubes. The top course is a 6-inch layer of coal 
dust, which will pass a three-sixteenth inch mesh. This gives a total depth of 
five feet, and when circumstances will permit this is the minimum depth that 
.should be used. It is unnecessary to have the filter tanks watertight, the effluent 
pipes being always open. 

The sludge should be removed by precipitation or otherwise before the sewage is 
passed on to the filter. Charging the filter is effected by means of narrow metallic 
distributing channels placed on the surface at distances of about one foot apart. 
The sewage is turned on for twelve hours at the rate of about 200 gallons per square 
yrard, and thus the filter works for twelve hours and rests a corresponding period in 
•each day. Dr. Fosbroke, the county medical officer for Worcestershire, from whose 
report to his council (1) the foregoing description of the filter and its method of working 
has been taken, states that his “ experience of the coal filter certainly brings me in 
full accord with the county medical officer for Staffordshire when he says * the 
results obtained from these filters are highly satisfactory,’ (and) on experimental 
data ‘the preference must be given to the coal filter.'” In a lecture delivered by 
Dr. Reid, the county medical officer for Staffordshire, before the members of the 
Sanitaxy Inspectors' Association, he contrasts the results of experiments made with 
three descriptions of filters: (1) one composed of sand and gravel, specially con¬ 
structed on Lowcock’s principle; (2) a filter made up of coke breeze; and (3) a 
Garfield coal filter, in which the superiority of the last-named filter was considered 
to be satisfactorily demonstrated; and a table is given showing that while the 
Lowcock filter, though inferior to the Garfield, was still fairly satisfactory, the coke 
breeze filter was, to all intents and purposes, useless. ” Coal,” says Dr. Reid, “ as 
a filtering medium is superior to gravel, and far superior to coke breeze;” and 
again, with reference to the Exeter septic tank method of purification, “ from the 
first I looked upon this method with disfavour—notwithstanding the urimimity with 

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2 18 


[Jan., 


which engineers and others hastened to embrace it,—because it appeared to me to 
violate the great principle which hitherto had guided us, of keeping the sewage as 
free as possible from putrefactive changes previous to its application to the land or 
artificial filters. Up to the present time (February, 1898) I have not seen any 
analytical results from this—the septic tank—method of treatment which have 
caused me to modify my opinion, although I need not say that when such evidence 
is forthcoming I shall at once admit my error.” It may be added that as late as a 
few weeks ago Dr. Reid had not changed the opinion which he had been led to 
form respecting the merits of the Garfield filter as contrasted with the results 
obtained by the system in use at Exeter. Mr. Garfield, in a letter dated August 
27th, 1898, says in reply to an inquiry, “ With reference to the sludge, I think that 
with domestic sewage a proportion of it can be got rid of by using a large-grain 
filter first; but before the sewage is run on to this it ought to be passed through a 
small settling or detritus tank to remove the heavy matter. Coal will be found 
the most suitable material for the large-grain filter also.” In coal districts this 
filter will be found to be a simple and inexpensive way of dealing with domestic 
sewage, as no costly tank is required—in one case the ground has simply been 
excavated and the vacant space filled in with coal in the manner described; the 
filtering material will last for an indefinite period, the “ royalty ” asked for is a merely 
nominal one, and the effluent is such that the most exacting river pollution inspector 
cannot possibly object to its direct passage into a water channel.—J. B. S. 

(') Report upon sewage disposal, bacteriological filters (tanks). 


THE TREATMENT OF IMBECILES AND EPILEPTICS. 

The Local Government Board have sanctioned the acquisition of a large area of 
land by the Leicester Board of Guardians for the purposes of an experiment in the 
treatment of the imbeciles and epileptics now in the Leicester workhouse. The 
proposed new departure is the practical outcome of an inquiry instituted on the 
Continent by the Chorlton Board of Guardians, with the view of ascertaining the 
advantages of the method of treatment now adopted in Belgium and Germany. 


SHOULD IMBECILES WORK? 

This question arose at the meeting of the Chester Board of Guardians lately 
upon a letter from Dr. Kenyon, the medical officer of health, stating that it had 
come to his knowledge that some of the imbeciles at the workhouse were employed 
mowing grass and chopping sticks. He thought the use of hedge clippers, scythes, 
&c., by them was highly dangerous. The clerk stated that the workhouse master 
considered that it was very much better that the imbeciles should be employed in 
some way, but he would submit the doctor's question to the department in London 
and have the matter settled. He (the clerk) thought if any of the imbeciles were 
dangerous it was the duty of the medical officer specifically to point them out. The 
master said in November the medical officer wrote a note to him strictly prohibiting 
the imbeciles from working or using any tools that were dangerous to themselves 
and others. The men were kept indoors for a short time until they clamoured to 
go to work. The matter was placed before the house committee, and they unani¬ 
mously decided that the imbeciles should be allowed to work in future.—Any 
further action was deferred pending the reply of the Local Government Board. 

It is somewhat surprising that Dr. Kenyon should be so ignorant of the treatment 
of the insane as to raise a question of this kind. Dr. Weatherly complains of the 
prejudice and ignorance of the general public; but it would seem necessary to 
inaugurate a crusade of information by beginning to instruct those who pre¬ 
eminently should know something of our work. 


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1899] 


NOTES AND NEWS. 


219 


MENTAL SUFFERING. 

A case of an unusual character came before the Leicester borough magistrates 
lately, when a commercial traveller was charged with causing mental suffering to 
his four children by threatening and neglecting them. The prosecution was insti¬ 
tuted by the Society for Preventing Cruelty to Children. The evidence showed that 
the defendant for three months had done no work, and had been almost continuously 
intoxicated. He threatened his children with violence, and the medical evidence 
showed that the children had suffered in their nervous system through fear on 
account of the threats of violence; but the defendant had never actually struck 
them, as they were protected by his wife. The Bench sentenced him to three 
months’ imprisonment with hard labour. , 

We quote this as corroborative of Dr. Macdonald’s position in regard to alcohol¬ 
ism as a cause of insanity, as reported in this number of the Journal. In this case 
a drunkard subjects his family to privations and incalculable mental stress. We 
congratulate the Society for Preventing Cruelty to Children on their activity in the 
matter. 


L’INTERMfDIARE DES NEUROLOGISTES ET DES ALIENISTES. 

We are favoured with the prospectus of a new journal which is to be printed in 
French, English, and German. It is designed to be a medium for the exchange of 
ideas on subjects connected with our department, principally in the form of notes 
and queries. The questions and answers are to be classed under the headings 
Neurology, Psychiatry, and Psycho-physiology. The most recent discoveries and 
theories will be recorded with references to original articles, and summaries of 
current knowledge will be published from time to time. The various congresses 
and meetings of learned societies in connection with these matters will be duly 
noticed in detail. We heartily commend this new departure, and hope that it will 
be widely supported by our readers. The subscription is only 7 fr. 50 per annum 
for the monthly issue, which will be published by Fllix Alcan, 108, Boulevard 
Saint-Germain, Paris. 


CORRESPONDENCE. 

From Dr. J. Sanderson Christison. 

The last issue of your esteemed Journal contains what purports to be a 
“ review ” of my brochure, Crime and Criminals , and which contains such a 
sweeping condemnation and gross misrepresentation of my little book, that in 
justice both to myself and the readers of the Journal I ask permission for a brief 
reply. 

The “ reviewer ” first observes that it u is not a scientific work,” while he in no 
way indicates that it is not, although he quotes two or three fragments of sentences 
which probably do not correspond with his views. He fails to observe what is 
stated in the preface, that the book was written for the general reader, and conse¬ 
quently the subject-matter is presented in a form and manner calculated to interest 
the public. He also says that it “ is conceived in execrable American-English, and 
teems with slang words redolent of the Bowerybut he fails to mention that the 
slang terms are quotations from the prisoners, and given as such to better indicate 
their meanings, which are often much easier understood than defined. 

The “ reviewer” flatly denies the truth of my statement that “ crimes are now 
nearly five times as numerous as forty years ago,” but he omits to say that I base 
the statement upon the official statistics of the United States, and thus refer to 
America only. I am aware that English statistics show a decrease of crime in late 
years. In America the ratio of incarcerated criminals to the general population 
was—for 1850, 1 to 3*442; i860, 1 to 1*647; 1870, 1 to 1*171 ; 1880, 1 to ‘850; 
1890, 1 to *757. 


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NOTES AND NEWS. 


[Jan., 

Dr. Paul Bartholow, of Philadelphia, has shown ( Journ . Amer. Medical Associa¬ 
tion, November 14th, 1896) that homicides in the United States were nearly six 
times more in 1895 than in 1885. The foregoing are facts the public of America 
must attend to and intelligently deal with. The " reviewer" declares the book is 
" unnecessary,” yet society and its machinery are chiefly responsible for the crime 
within it, and I know of no other book which presents typical cases of every-day 
offenders described in a way conducive to a better understanding by the public of 
the main factors in our criminal problem. And surely no one author can expect to 
reach the whole reading public. Medical psychologists do not make our laws. 

So far, at the hands of " reviewers ” my book has met with only commendation 
or tirade, and surely tirade is not criticism, nor even review. Let reviewers observe 
the golden rule, and be at least fair and honest. They have the facts before them, 
if they do not always have the requisite understanding. 

[I have been favoured with the perusal of the above letter anent my review of 
Dr. Christison’s book, Crime and Criminals , in the last number of the Journal. 
Dr. Christison first quarrels with me for saying that his book " is not a scientific 
work,” and then proceeds to admit the justice of the statement; ditto as regards 
the slang terms employed. As to the character of the English in which the text is 
conceived, a glance at the book itself will suffice to condone my use of the word 
"execrable.” He next accuses me of "flatly denying” his statement that "crimes 
are nearly five times as numerous as forty years ago,” whereas the words I used 
were " which we venture to doubt.” As to the book being " unnecessary,” that is 
only my opinion as reviewer. I must apologise to Dr. Christison for not having 
been able to take his book seriously, and for having treated it with a levity which he 
evidently considers undeserved. As I remain unable, after re-perusal of it, to modify 
my already expressed opinion, I must ask him to ascribe my want of appreciation 
to a lack of the " requisite understanding.”— The Reviewer.] 


THE LUNACY COMMISSION. 

The retirement of Dr. Southey from the Lunacy Commission will be a source of 
regret to those members of our association who have had the best opportunity of 
knowing his worth, and the uniformly high ideas that he has maintained in the dis¬ 
charge of his duties. It is to be hoped that the onerous character of those duties, 
owing to the obvious and notorious understaffing of the Commission, has not 
had a share in leading to his retirement. 

Dr. Sydney Coupland, who succeeds Dr. Southey, has a reputation both 
professional and individual that ensures his becoming a very successful member of 
the Commission. His long connection with the Middlesex Hospital has given him 
a very wide circle of friends, who regret the loss of his services to that institution, 
and who, we are informed, intend to express that regret in the practical form of a 
handsome testimonial. 


OBITUARY. 


John Bywater Ward. 

John Bywater Ward, M.A., M.D.Cantab. Born March 18th, 1844; died October 
3rd, 1898. Medical Superintendent and Secretary of the Warneford Asylum, 
Oxford. 


Dr. Ward was a native of Leeds. He was the second son of Mr. William 
Sykes Ward, solicitor, of that city, and his wife Caroline, daughter of Mr. John 
Bywater, also of Leeds. In 1856 he entered the Leeds Grammar School, 
where he received the early part of his general education. On leaving the 
grammar school he became a student at the Leeds School of Medicine. He then 
entered at Caius College, Cambridge, as a Scholar, and graduated B.A. in 1867, 
taking a Second Class in Natural Science. He took the degree of M.B. in 1868, 
and became M.D. in 1872. He also held the diplomas of M.R.C.S.Eng., and 
L.S.A. His education being finished, Dr. Ward became one of the house surgeons 
to the Sheffield Infirmary, a post which he appears to have held for about two 
years. He then accepted a clinical clerkship at the West Riding Asylum under 


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1899.] 

the directorship of Dr. (now Sir) Tames Crichton Browne. At this time he con¬ 
tributed to the West Riding Asylum Reports a paper on the “ Hypodermic 
Injection of Morphia in the Treatment of Insanity.” He was next appointed 
Assistant Medical Officer to the Warwick County Asylum, under the late Dr. 
Parsey, as Medical Superintendent, and here he remained for four years. 

On September 17th, 1872, Dr. Ward was elected to the conjoined offices of 
Medical Superintendent and Secretary of the Warneford Asylum, Oxford. Up to 
this date it had been a rule of the Warneford Asylum that the Medical Super¬ 
intendent should be a married man at the time of his appointment, and that 
his wife should be matron. With the election of Dr. Ward, who was then a 
bachelor, a new departure was inaugurated, and a matron was appointed at the 
same time. In 1880 Dr. Ward married Miss Frances Toone, youngest daughter of 
William Wastneys Toone, Esq., of Landcote Grange, Yorkshire. In spite of 
much difficulty and suffering from chronic ill-health, Dr. Ward discharged his 
various and responsible duties, involving a great deal of clerical and financial work, 
with ability and success for twenty-five years. Under his direction the Warneford 
Asylum fully maintained its high character among the Registered Hospitals of 
England. An Assistant Medical Officer was added to the staff, and the building 
was twice enlarged. Between Dr. Ward and his Committee of Management the 
greatest harmony and good feeling existed during the entire period of his tenure of 
office. He retired at Michaelmas, 1897, on a pension of £400, willingly granted; 
and the Governors, in a special minute, recorded their appreciation of the valuable 
services he had rendered to the Warneford Asylum. On his retirement Dr. Ward 
settled with his family in Oxford, where he had purchased a house. But his 
health, always imperfect, gradually declined. An abscess formed in a kidney, and 
he sank thirty-six hours after an operation had been performed by Mr. Winkfield, 
surgeon to the Radcliffe Infirmary. He was attended also by Dr. Gray, Consulting 
Physician to the Warneford Asylum, and by Dr. Proudfoot of Oxford. He was 
buried in the churchyard of Cowley St. John, Oxford. Dr. Ward is survived by 
his widow and four children—two sons and two daughters. 

W. R. Ancrum. 

The death on October 9th of Dr. W. R. Ancrum, of St. Leonard's Court, 
Gloucester, at the age of eighty-two, deserves notice in the pages of this Journal, 
for much of his work and time during the last thirty years of his life had been 
devoted to asylum administration. He had a successful career as a student of 
University College Hospital, as house surgeon of that hospital, as assistant to 
Mr. Liston, and as a practitioner both in this country and in South America. 
When he retired from the active pursuit of his profession he settled in Gloucester¬ 
shire, and there his capacity for public work and his powers as an administrator 
were at once recognised. From the early sixties to within two years of his death 
be was associated with the management of the county infirmary, of the county 
asylum, and of Barnwood House Hospital for the Insane, and for many years he 
was chairman of the committees of these institutions. He left each of them more 
flourishing than he found it. He was a strong man, of sound judgment, keen 
discrimination, profound but regulated sympathy, and rigorously just in his 
dealings. He had in a high degree the capacity for entering into and sharing the 
enthusiasms of younger men, and it was this even more than his great qualities as 
an administrator which endeared Dr. Ancrum to the superintendents and other 
officers of the institutions with which he was connected. 

Carlo Giacomini. 

By the death of Professor Carlo Giacomini, of the University of Turin, Italy has 
lost one of her most illustrious sons. He was an indefatigable worker in anatomy, 
embryology, and anthropology. His works are well known, specially his Guide to 
the Study of the Cerebral Convolutions published some twenty years ago, and his 
Anatomy of the Negro, which throws light upon obscure points in evolution. Pro¬ 
fessor Giacomini’s work on the Brains of Microcephalies is also worthy of 
remembrance. 


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NOTES AND NEWS. 


[Jan., 


NOTICES BY THE REGISTRAR. 
Examination for the Nursing Certificate . 


One hundred and forty-eight candidates applied for admission to the November 
examination for this certificate. Of this number 119 were successful, 11 failed to 
satisfy the examiners, 8 withdrew, and the results of the examination of 10 candi¬ 
dates from South Africa have not yet been received. 

The following is a list of the successful candidates: 

Kent County Asylum, Barming Heath , Maidstone.—Males : Thomas Edwin 
Cooper, Edgar Charles Foote. Females: Laura Barton, Edith Georgina Rebecca 
Darwin, Amelia Green, Elizabeth Harvey, Clara Peel, Alice Francis Amelia Rowe, 
Mary Louisa Rowe, Elizabeth Sharpies. 

County Asylum, Powick, Worcester. — Males: Albert Edward Bott, George 
Matthews. 

County Asylum , Bodmin, Cornwall. — Males: Charles Bray, Thomas Robert 
Hards. Females: Edith Blight, Francis Helen Davey, Louisa Wilkinson. 

County Asylum , Parkside, Macclesfield. — Males: Joseph Herman, William 
Muir. Females: Sarah Jane Baynham, Clara Elizabeth Cantrill, Margaret Ellen 
Hewitt, Martha Jane Jones, Mary Ellen Johnson, Blanche Vernon McLean, 
Gertrude Mellor, Emma Sharp. 

County Asylum, Mickleover, Derby. — Females: Sarah Annette Brown, Rose May 
Daws, Sabina Foster, Hylda Gordon, Kate Reavill, Sarah Stretton. Male: Allen 
Robbins. 

County Asylum, Thorpe, Norwich , Norfolk. — Males: William Arthur Newson, 
Alfred James Orchard, George Spalding, Walter Wilkinson, George Robert 
Whatley, William Walker Lishman. Female: Alice Maud Smith. 

County Asylum , Hatton , Warwick. — Males: George Arthur Harrison, John 
William Owen, William Vincent. 

North Riding Asylum , Clifton, York. — Males: John Cole, Joseph Denton, 
William Arthur Hill, Thomas Milnthorpe, Arthur William Parry, William Rigby, 
Frederick Waterhouse. Females ; Jane Baxter, Clarissa Morrell, Ada Jane Parker, 
Caroline Potter, Mabel Bishop Simms. 

County Asylum, Lancaster. — Females: Priscilla Huddart, Mary Hughes, Ada 
Holmes, Margaret Alice Harper, Eliza Remington, Edith Sharpe, Bertha Schussler, 
Clara Thompson, Ellen Tyson. 

County Asylum, Morpeth, Northumberland. — Females: Elizabeth Allen, Mary 
Murray, Winifred Pringle. 

Borough Asylum, Ryhope, Sunderland. — Males: George Harrison, Thomas 
Noble, William Joseph Smith. Females : Annie Elizabeth Amelia Ayre, Margaret 
Brierley, Florence Hobbs. 

Borough Asylum, Milton, Portsmouth. — Males: Thomas Edmonds, Walter 
Gubby, James Miller, Walter William Wellstead. 

Holloway Sanatorium, Virginia Water, Surrey. — Males: George Foreman 
Beales, John Dickinson, John George Lufton Harries, Thomas William Maynard, 
Alfred Preston, Walter Marsden. Females: Sarah Jane Brereton, Lily Cutler, 
Adelaide Elston, Elizabeth Lyon, Marie More, Annie Munday. 

The Retreat, York. — Female: Mary Hartas. 

Midlothian and Peebles District Asylum, Rosslyn Castle, Edinburgh. — Males: 
Alexander M. Chisholm, John Henderson, John McHardy, James Turnbull. 
Females : Maggie Duncan, Mary McFadden. 

District Asylum, Inverness. — Male: Angus Mackay. Females : Maria Wright 
Fraser, Margaret Knox. 

District Asylum, Londonderry, Ireland. — Males: Thomas Kelly, John Lynch, 
James McMorris, William McMoyle, Hugh McGarvey, John McDaid, Charles 
McBride. Females: Elizabeth Christie, Joyce Anna Nixon, Bessie Nixon, Sarah 
Ann Wilson. 

District Asylum, Mullingar, Westmeath, Ireland. — Males: Francis Murphy, 
John Pointon, George Rouse. Females: Kate Newton, Kate Nally, Bridget 
Shannon. 


Private Nurses. — Females: Elizabeth Goodlet, Ada L. Middleton. 
The following is a list of the questions which appeared on the paper: 


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1899.] 

1. What is an artery and what is a vein? What is the difference between the 
blood in an artery and the blood in a vein ? 2. What bones form the thorax ? 
What does it contain ? 3. What is respiration ? What changes take place in the 
blood and air during respiration ? 4. What are the signs of fracture of a bone ? 
What steps would you take for first aid to a patient who appeared to have broken 
his leg ? 5. What precautions are to be observed by attendants in bathing patients ? 
6. How does a melancholic patient look, and how does he conduct himself P What 
things ought an attendant to observe and report about a melancholic patient ? 7. 
What class of patients are most likely to choke at meals P What precautions would 
you take to prevent choking P What would you do for a patient who appeared to 
be choking ? 8. What can be done to break a patient of the habit of picking sores 
in his skin ? 9. What is meant by seclusion ? What ought an attendant to do 
before secluding a patient? 10. What can an attendant do to help a sleepless 
patient to obtain sleep P 

The next examination will be held on Monday, May 1st, 1899, and candidates are 
earnestly requested to send in their schedules, dulv filled up, to the Registrar of the 
Association not later than Monday, April 3rd, 1899, as that will be the last day 
upon which, under the rules, applications for examination can be received. 

Note . 

As the names of some of the persons to whom the N ursing Certificate has been 
granted have been removed from the Register, employers are requested to refer to 
the Registrar, in order to ascertain if a particular name is still on the roll of the 
Association. In all inquiries the number of the Certificate should be given. 


Examination for the Professional Certificate . 

The following gentlemen were successful at the recent examination for the Cer¬ 
tificate in Psychological Medicine held on December 15th, 1898: 

Examined at Bethlem Hospital. —Dr. Thomas Gibson, Dr. Wilfred Brougham 
Warde. 

Examined at the Royal Asylum , Morningside, Edinburgh. —Dr. George A. Rorie, 
Dr. James Muir Rutherford. 

The following is a list of the questions which appeared on the paper : 

1. What is meant by responsibility? State the ways in which alcoholic excess 
may affect responsibility. 2. What are the indications which would lead you to 
make use of the following drugs in the treatment of insanity: Sulphonal, trional, 
paraldehyde, hyoscine, chloralamide ? What dangers may arise from their use P 
3. Enumerate the forms of mental derangement associated with the puerperal state. 
Describe a typical case of puerperal mania and its treatment. 4. Distinguish 
between idiocy and imbecility. Mention the best known types of idiocy. 5. 
Describe a case of systematised insanity. 6. Describe the alterations in the cortical 
cells due to post-mortem change ; also the alterations associated with the adminis¬ 
tration of certain poisons, and discuss the bearing of these various conditions upon 
the views hitherto entertained of the morbid anatomy of general paralysis. 


The next examination for the Certificate in Psychological Medicine will be held 

in July» 1899. 

The examination for the Gaskell Prize will take place at Bethlem Hospital, 
London, in the same month. 

Due notice of the exact dates will appear in the medical papers. 


The name of Dr. John Blackwood, who was successful at the examination for the 
Certificate in Psychological Medicine held on July 7th, 1898, at Bethlem Hospital, 
London, was accidentally omitted from the list published at page 859 of the 
October, 1898, number of the Journal, and the names of Drs. Hamilton C. 
Marr, Alexander Keith Campbell, and George Stephen should have been given in 
the list of holders of the Medico-Psychological Certificate on page xxiii of the same 
number. 


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NOTES AND NEWS. 


[Jan., 1899. 

For further particulars respecting the various examinations of the Association, 
apply to the Registrar, Dr. Spence, Burntwood Asylum, near Lichfield. 


THE PRIZE DISSERTATION. 

Although the subjects for the essay in competition for the Bronze Medal and 
Prize of the Association are not limited to the following, in accordance with custom 
the President suggests— 

1. On the anatomy and physiology of the superficial layer of the cerebral cortex 
in health and disease. 

2. On the prevention and treatment of phthisis pulmonalis in asylums for the 
insane, with special reference to its frequency and causation. 

3. On the evolution of asylum architecture, and the principles which ought to 
control modern construction. 

The Dissertation for the Association Medal and Prize of Ten Guineas must be 
delivered to the Registrar, Dr. Spence, Burntwood Asylum, near Lichfield, before 
May 30th, 1899, from whom all particulars may be obtained. 

By the rules of the Association the Medal and Prize are awarded to the author 
(if the Dissertation be of sufficient merit), being an Assistant Medical Officer of 
any Lunatic Asylum (public or private), or of any Lunatic Hospital in the United 
Kingdom. The author need not necessarily be a member of the Medico-Psycho¬ 
logical Association. 


NOTICES OF MEETINGS. 
Medico-Psychological Association. 

General Meeting. —At Chester on the 16th February. 

South-Eastern Division. —At Chartham Asylum on the 5th April. 
South-Western Division. —At Grand Pump Room Hotel, Bath, 18th April. 
Northern Division. —At Hatton Asylum, Warwick, on 12th April. 

Scottish Division. —At Glasgow on 9th March. 


APPOINTMENTS. 

A. N. Boycott, M.D.Lond., appointed Medical Superintendent to the Hertford¬ 
shire County Asylum, Hill End, St. Albans. 

Sidney Coupland, M.D.Lond., appointed Commissioner in Lunacy for England. 

Arthur N. Davis, L.R.C.P., L.R.C.S.Edin., appointed Medical Superintendent to 
the Devon County Asylum. 

Dr. Peers MacLulich, B.A., M.B., Ch.B.Dublin, appointed Second Assistant 
Medical Officer to the Joint Counties Asylum, Carmarthen. 

W. F. Menzies, M.D., B Sc.Edin., appointed Medical Superintendent to the 
Third Staffordshire Asylum, Cheddleton, near Leek. 

Charles R. Scott, M.B.Edin., appointed Assistant Medical Officer to the Warne- 
ford Asylum, Oxford. 

T. Goldie-Scot, M.B., C.M.Edin., M.R.C.S., L.R.C.P., appointed Assistant 
Medical Officer to the Royal Asylum, Glasgow. 


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JOURNAL OF MENTAL SCIENCE. 



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THE 

JOURNAL OF MENTAL SCIENCE. 


[i Published by Authority of the Medico-Psychological Association 
of Great Britain and Ireland 1] 


No. 189 [ N£ n W o 8 J s T] APRIL, 1899. VOL. XLV. 


Part I.—Original Articles. 

The New Inebriates Act . By A. Wood Renton, Barrister- 

at-Law. 

After many years of agitation and controversy, the first 
instalment of a much-needed reform of the law as to inebriates 
has been conceded by the Legislature. The aim of the present 
article is to subject the Inebriates Act, 1898, which came into 
operation on January 1st, 1899, to a somewhat minute and 
critical examination, in the hope at once of suggesting points 
for future amendment, and of throwing light on difficulties that 
may arise in its practical administration. 

The Act divides itself roughly into two sets of provisions, 
which it is necessary to distinguish : 

I. Amendments of the Inebriates Acts, 1879 and 
1888. 

II. New Powers of Dealing with Criminal Ine¬ 
briates. 

We will deal with these classes in turn. 

I. Amendments of the Inebriates Acts, 1879 and 
1888. 

( 1 ) No Powers of Compulsory Committal are given .—The first 
point that calls for observation is that, in spite of the unanimous 
demand for them on the part of every Parliamentary committee 
that has inquired into the subject during the last quarter of a 
century, and of the licencees of the retreats established under 

XLV. 








228 


THE NEW INEBRIATES ACT, 


[April, 


the Acts of 1879 and 1888, no powers for the compulsory com¬ 
mittal of non-criminal inebriates to places of detention have been 
brought into existence by the new statute. It was not, 
indeed, expected that they would be ; but it is important to 
emphasise once more the fact that the policy embodied in the 
Acts of 1879 and 1888 cannot be successfully carried out or 
developed until this defect in the law has been removed. It may 
be worth while to sum up in a few sentences the case for 
compulsory committal. Practically the whole body of expert 
opinion in the country is in its favour. The majority of ine¬ 
briates cannot be induced to apply for their own committal; and 
the resolution of many of those who do so apply evaporates 
before the statutory formalities necessary to their admission to 
a retreat can be complied with. Moreover committals under 
the Acts of 1879 and 1888, where they are effected, are already, 
to a large extent, compulsory, since the friends of patients put 
upon them a moral pressure which they are unable to resist. 
Finally, compulsory committal has been tried with entirely 
successful results in America and on the Continent (cf. Kerris 
Inebriety , second edition). Compulsory powers would be amply 
safeguarded against abuse by providing, as the Committee of 
1893 suggested (c. 7008 A [8]), for an appeal to a divisional 
Court against any order made pursuant to the Act. What is 
further needed is a section like section 116 of the Lunacy Act, 
1890, for the judicial application of the property of inebriates. 

(2) Most of the Minor Reforms of the Legislation of 1879 and 
1888 which have been demanded are conceded ’ — (a) Duration of 
licence .—There was considerable complaint (see first Report of 
Inspector of Retreats, 1881, c. 354, p. 1, par. 5) that the thirteen 
months’ maximum duration of a licence under sect. 6 of the 
Act of 1879 was too short, on the ground that it both dis¬ 
couraged application for licences, and prevented licensees from 
laying out capital on the improvement of their retreats. The 
maximum duration is now two years (Act of 1898, s. 15). 

(b) Maximum period of voluntary detention .—Under the Act 
of 1879 this was one year. In many cases that was felt to 
be too short a time to effect a cure, and the limit has now 
(Act of 1898, s. 16), in accordance with a recommendation 
of the Departmental Committee of 1893 (c. 7008 A [3] ), 
and a clause in Lord Herschell’s bill of 1894, been raised to 
two years. It will be noted, of course, that it is for the inebriate 

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BY A. WOOD RENTON. 


I 899.] 


229 


at the time of the application to fix the limit of his detention. 
The statute only enlarges the possible limit. 

{c) Simplification of procedure .— At quite a number of points 
the procedure under the Acts of 1879 and 1888 was unsatis¬ 
factory. Under the Act of 1879, applications for admission 
to retreats had to be attested by two justices having jurisdiction 
under the Summary Jurisdiction Acts in the place where the 
matter requiring their cognisance arose . The difficulty of finding 
two such justices was, however, an obstacle to the efficacy of 
the statute, and the requisition was repealed by sect. 3 of the 
Act of 1888. But even so the procedure was cumbrous, and 
the advocates of fresh legislation as to inebriates have contended 
that the attestation of a single justice should be sufficient. The 
16th section of the Act of 1898 makes it so. Again, no facilities 
were afforded by the Acts of 1879 an< ^ 1888 for the extension 
of the term of a patient’s detention, or for his readmission into a 
retreat. In either case the whole minuet of proceedings 
attendant on an original application had to be gone through. 
The new Act deals with this difficulty. Section 10 enables the 
extension or readmission to be effected “ in like manner as an 
habitual drunkard may be admitted under section 10 of the 
Habitual Drunkards Act, 1879, as amended by section 4 of 
the Inebriates Act, 1888, and by this Act,” the statutory 
declaration being dispensed with, and the attesting justice not 
being required to satisfy himself that the applicant is an 
habitual drunkard. The net result of this somewhat cumbersome 
provision is that extension or readmission may now be effected 
on the written application of the patient to the licensee, attested 
by a single justice : no statutory declaration by two witnesses 
that the applicant is an inebriate, and no inquiry by the attest¬ 
ing justice into the question, being necessary. Once more, the 
machinery in the Acts of 1879 and 1888 for dealing with cases 
of escape was singularly defective. Two distinct classes of 
escapes were dealt with—escapes from retreats, and escapes of 
patients during leave of absence from the persons in whose 
charge they were placed. The first defect in the old law was 
a curious casus omissus. Section 26 of the Act of 1879 pro¬ 
vided for the apprehension of an habitual drunkard escaping either 
from a retreat or while absent on leave, on the warrant of “ any 
justice or magistrate having jurisdiction in the place or district 

where he is found, or in the place or district where the retreat from 

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230 


THE NEW INEBRIATES ACT, 


[April, 


which he escaped is situate.” It will be observed that from the 
wording of this section the warrant could only be issued in the case 
of an escape during absence on leave by a justice having jurisdic¬ 
tion in the place where the patient was found. Section 18, 
sub-section (2), of the Act of 1898 supplies this hiatus by en¬ 
abling the warrant to be issued by any justice having jurisdiction 
in the place where the person in charge of the patient resides. 
Again, while the Act of 1879 provided that (section 21) where 
a licence for leave of absence was forfeited or revoked (and 
escape from a person in charge was an ipso facto ground of for¬ 
feiture [section 22]), the time during which such habitual 
drunkard was so absent from the retreat should be excluded in 
computing the time of his detention, there was no similar enact¬ 
ment in regard to patients, not absent on leave, escaping from 
retreats. Section 18, sub-section (1), of the Act of 1898 pro¬ 
vides for the exclusion in such cases of the time between escape 
and return. It may be pointed out that there is some doubt, 
from the language used in section 21 of the Act of 1879, 33 to 
whether any time that may elapse between the escape and the 
recapture of a patient absent on leave is to be excluded in 
computing the term of his detention. Section 21 provides for 
the exclusion of “ the time during which such habitual drunkard 
was so absent from the retreat.” But a prior part of the section 
indicates that the words “ so absent ” mean “ absent under 
licence,” whereas, on escape, a licence is ipso facto forfeited 
(section 22), and therefore ceases to exist. 

The point is fine, and possibly unsound ; but in any sub¬ 
sequent legislation on the subject, any doubts in regard to it 
might be expressly negatived. Another hiatus in the Acts 
seems to call for passing mention. Section 22 of the Act of 
1879 provides for the revocation of a licence by the Secretary 
of State, &c., and that “ thereupon the habitual drunkard to 
whom the licence related shall return to the retreat.” Prob¬ 
ably a patient failing or refusing to return after such a re¬ 
vocation could be recaptured as an escaped patient under 
section 26. But the question might advantageously be settled 
by express enactment, definite provision being made, here 
again, for the exclusion of an interval between revocation and 
recapture in the computation of the time of detention. 

There are more serious objections to be urged, however, 
against the law as to escapes as it still stands. In the first place, 

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while any officer, &c., of a retreat who induces or wilfully assists 
the escape of a patient is guilty of an offence against the Act 
under section 24, sub-section (2), such an escape does not 
appear to be an offence on the part of the patient. It ought 
to be made one. In the second place, although the licensees 
of retreats have long complained that the requirements of the 
section dealing with escapes (section 26)—the swearing of an 
information, the finding of a magistrate with jurisdiction, and 
the issue of a warrant—frequently occupy so much time that 
the escaped patient cannot be recaptured, no amendment of this 
unnecessarily intricate machinery has been effected. 

Only three other amendments of the Act of 1879 are effected. 
The case of the death of a patient under licence—another hiatus 
in the Act of 1879—is covered by a section (Act of 1898, 
sect. 19) practically identical with section 27 of the Act of 1879, 
relating to the death of a patient actually detained in a retreat. 
The licensing authorities under the Acts of 1879 and 1888 
were the borough justices in boroughs and the county justices 
in counties (Act of 1879, sect. 4, 5, Schedule I). Now they 
are the borough councils and county councils respectively ; the 
clerk of the local authority being the town clerk in boroughs, 
and the clerk of the county council in counties (Act of 1898, 
sect. 13). A county council may delegate any of its powers as 
such local authority ( ibid .). A county or borough council may 
contribute towards the establishment or maintenance of retreats, 
and any two or more may combine for such purpose (ibid., 
sect. 14). Lastly, the Secretary of State is enabled to make 
arrangements with respect to (a) the procedure for admission, 
extension of the term of detention, or readmission ; ( b ) medical 
or curative treatment, including (a very necessary provision) the 
enforcement of such work on patients as may be necessary for 
their health ; ( c ) inspection of retreats ; ( d) other matters for 
carrying out the Acts (ibid., sect. 20). Regulations made under 
this section are not to come into force till they have lain on the 
table of each House of Parliament for four weeks while that 
House is sitting, and therefore do not require publication 
under the Rules Publication Act, 1893, and the making of 
them and their date are to be notified in the London Gazette 
(ibid., sect. 21). 

II. New Powers of dealing wmr> Criminal Ine- 

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232 THE NEW INEBRIATES ACT, [April, 

BRIATES. —The Act provides for the establishment and recog¬ 
nition of two classes of reformatories : 

1. State Inebriate Reformatories . 

2 . Certified Inebriate Reformatories . 

Some of the provisions of the statute have special applica¬ 
tion to each of these separately. Others apply to both classes 
jointly. These provisions must now be noticed in turn. 

1. State Inebriate Reformatories .—The Secretary of State is 
enabled to establish State Inebriate Reformatories, and for this 
purpose—with the approval of the Treasury—to acquire land 
and erect buildings, or appropriate the whole or any part of 
any buildings vested in him or under his control, and any ex¬ 
penses incurred by him in connection therewith are to be met 
“out of money provided by Parliament” (Act of 1898, 
sect 3). Subject to regulations which the Secretary of State is 
empowered to make for the management of these reformatories, 
and for the classification and treatment of their inmates, and 
for absence on leave, the Prison Acts, 1865—1898, includ¬ 
ing the penal provisions of such Acts, apply to them. But no 
regulation ( semble either by the Secretary of State or by the 
Prison Commissioners) is to authorise the infliction of corporal 
punishment in any State Inebriate Reformatory (Act of 1898, 
Sect. 4.) The Home Secretary has indicated in a recent 
circular letter to Judges, Chairmen of Quarter Sessions, and 
Recorders, that no State Inebriate Reformatory is to be estab¬ 
lished in England in the meantime. 

2. Certified Inebriate Reformatories — Applications . — The 
Secretary of State is empowered, on the initiative of the 
council of any county or borough, or of any persons desirous 
of establishing an Inebriate Reformatory, to certify it as such 
if he is satisfied of the fitness of the proposed establishment, 
and of the applicants intending to maintain it (Act of 1898, 
sect. 5 [1] ). The procedure on applications is now prescribed 
by model regulations made by the Secretary of State under 
sect. 5 (2). These regulations are referred to in this article as 
M. R. Applications for certificates are to be addressed to the 
Under Secretary of State, Home Office, Whitehall, and to give 
the following particulars :—(i) Name proposed for reformatory. 

(ii) Names of managers, corresponding secretary, and treasurer. 

(iii) Description and plan of site ; the land must be of healthy 
character, at some distance from large centres of population, 

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and must allow not less than one acre for every ten patients in 
the case of male reformatories, and half that quantity in the 
case of female, (iv) Full plans exhibiting (a) adequate and 
separate accommodation for dormitories, day-rooms, and work¬ 
shops ; (<b ) proper infirmary accommodation ; (c) proper asso¬ 
ciated dormitories for healthy inmates, (v) Number—not less 
than twenty-five—of inmates proposed to be received, (vi) 
Sex: if different sexes are to be received, the buildings and 
grounds occupied by them must be absolutely separated, (vii) 
Whether inmates of certain classes only, e.g. of specified reli¬ 
gious denominations or from specified localities, (viii) Rules: 
these should either incorporate or be based on the Model 
Regulations, and must be approved by the Secretary of State 
before any inmates are received, and the payment of the 
Treasury grant ( vide inf.) is contingent on their observance, 
(ix) Names of superintendent ( vide inf), medical officer (vide 
inf), and proposed staff, (x) Statement of proposed work for 
inmates, and arrangements as to individual training (M. R., 
App. X, 1). It should further be noted that an application for 
a certificate is to be deemed to be an undertaking on the 
part of the managers (vide inf) to feed, clothe and main¬ 
tain any person who may be committed to their care with 
their consent for the period of the sentence, subject to the 
regulations approved for their institution (M. R. 1 [6] ) ; and 
further, that as no certificate can be granted till the site and 
plans have been approved, such approval should in every case 
be obtained before money is spent or contracts are entered 
into in connection with a new institution (ibid., App. I). If 
the Secretary of State is satisfied on the points above indicated 
he may grant a certificate containing (M. R. 1 [2] ) any condi¬ 
tions that he may prescribe, and such certificate is to remain in 
force until it is withdrawn or surrendered (ibid. 1 [3]). A cer¬ 
tificate is not to be surrendered till the Secretary of State is 
satisfied that proper arrangements have been made for the dis¬ 
posal of the inmates (ibid., 1 [5] ). The grant, withdrawal, or 
surrender of a certificate is to be notified in the London Gazette 
(ibid., 1 [4] ). 

The Managers. —The expression “ managers ” in relation to 
a certified inebriate reformatory means any persons having the 
management or control of the reformatory’ (Act of 1898, sect. 
27). The duties of the managers in relation to applications for 

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234 


THE NEW INEBRIATES ACT, 


[April, 


certificates are stated under the heading “ Applications,” sup. 
Their other general duties are (i) to furnish the Secretary of 
State with a yearly statement of the receipts and expenditure 
of the reformatory in such form as may be (none has yet been) 
prescribed (M. R. 2); (ii) to acquaint the Secretary of State 
with any changes in the personnel of the staff {ibid., 3); (iii) to 
make application quarterly to the Secretary of State for the 
Treasury grant, forwarding the necessary particulars of the 
number of inmates during the quarter, and the length of time 
each has been detained in the reformatory {ibid., 5); (iv) to deal 
with the question whether application should be made to the 
county court under sect. 12 of the Act of 1898 ( vide inf.) ; 
and (v) to deal with various questions of administration and 
discipline which are noticed incidentally under other headings. 

The Superintendent .—The superintendent is to reside in the 
reformatory, and is not to be absent without due arrangements 
for the discharge of his duties having been made to the satis¬ 
faction of the managers (M. R. 6). He is to report to the 
Secretary of State the reception of every inmate, sending a 
copy of the commitment or order of court {ibid., 7). He is to 
be responsible for the observance of the regulations and the 
proper conduct of the officers of the reformatory {ibid., 8), and 
for communicating to inmates the regulations affecting them 
{ibid., 13), and to carry out the rules as to the employment and 
industrial training of inmates {ibid., 10). He is to keep and be 
responsible for a journal and such other books and records as 
may from time to time be prescribed {ibid., 9). His duties as to 
inspection and visitation are {a) to inspect daily the whole 
reformatory, and see every inmate once in twenty-four hours 
{ibid., 11); {b) to visit daily all inmates while employed at 
labour {ibid., 11) ; and (< c) to see that every inmate under 
punishment is visited during the day at intervals of not more 
than half an hour by the appointed officer {ibid., 29). He is to 
take every precaution to prevent escapes {ibid., 12 [ 1 ] ) or fires 
{ibid., 26), to assure himself that all gates are locked at the 
proper times, and that all the keys of the reformatory are in 
their proper places {ibid., 12 [2]; and to pay attention to the 
ventilation, drainage, &c., of the reformatory {ibid., 23). The 
superintendent is, further, to inform the managers or inspector 
{vide inf) of the desire of any inmate to see them {ibid., 28) ; 
to take care that no inmate is subjected to any punishment 

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235 


without the approval of the medical officer (ibid., 30) ; to assist 
in providing inmates with employment on their discharge, and 
in preventing them from falling again under the influence of 
drink (ibid., 32). He may read every letter addressed to or 
written by an inmate, and may use his discretion in communi¬ 
cating to or withholding from an inmate at any time the contents 
of a letter addressed to such inmate—why should this latter pro¬ 
vision not be extended, as in the Lunacy Acts (see sect. 41 [1] 
of the Lunacy Act, 1890) to letters written by an inmate to 
private correspondents ?—noting every case of such withholding 
in his journal. All letters withheld are to be forwarded to the 
inspector (ibid., 34). The superintendent is to inquire with 
respect to every inmate, on reception, whether he has any real 
and personal property more than sufficient to maintain his 
family, and to lay the result of his inquiries before the managers 
and the Secretary of State (ibid., 34). As to consequential 
proceedings see inf\ The superintendent is to (a) call the 
attention of the medical officer to any patient whose state of 
body or mind seems to require notice (ibid., 14), or who is ill, 
—a daily list of sick inmates is to be furnished (ibid., 1 5), and to 
carry into effect the written recommendation of the medical 
officer for the alteration of the discipline or treatment of any 
inmate (ibid., 19), or for separating from the other inmates any 
inmate labouring or supposed to labour under any infectious, 
contagious, or mental disease (ibid., 20), reporting forthwith to 
the inspector if in any case the recommendations of the medical 
officer are not carried out (ibid., 21); (b) report without delay 
to the inspector the case of any patient as to whom the 
medical officer is of opinion that his life will be endangered by 
further detention, or that he is unfit totally and permanently 
for reformatory discipline, or that his mind is becoming impaired 
(ibid., 18); (c) notify to relatives any case assuming in the 
medical officer’s opinion a dangerous aspect (ibid., 22); and (d) 
notify any case of death to the managers, the nearest relative, 
the coroner, and the Secretary of State (ibid., 16), who is also 
to be furnished, if an inquest is held, with the finding of the 
jury and the facts elicited (ibid., 17). Finally, the super¬ 
intendent may examine all persons and vehicles going in or out 
of the reformatory, and may exclude any person who refuses to 
be examined (ibid., 24); and may remove any visitor to the 


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236 THE NEW INEBRIATES ACT, [April, 

reformatory or to an inmate whose conduct is objectionable, 
recording the fact in his journal. 

The Medical Officer .—The medical officer is entrusted with 
the general care of the health of the inmates, and is to report to 
the managers and notify the superintendent of any circumstances 
requiring attention on medical grounds. These reports are to 
be shown to the inspector on his visits, and in cases of import¬ 
ance copies are to be transmitted to the inspector (M. R. 35). 
The medical officer is to visit the reformatory at least once 
every day, and every inmate at least twice a week (ibid., 36). 
He is further required to visit (a) every day such inmates as 
complain of illness, reporting to the superintendent in writing as 
to their fitness for labour, and the sick in the infirmary (ibid., 
37) I P) every day, or oftener, any inmate under punishment 
to whom his attention is specially called (ibid., 38) ; (c) at once 
any patient of whose illness he receives information (ibid., 37). 
He is to examine every patient on reception, and to report the 
result to the Secretary of State (ibid., 39) ; to examine washing 
places, &c. (ibid., 40), and food, &c. (ibid., 41), and report to the 
superintendent on any defect or insufficiency thereof, and to 
send accounts of cases and statistical records as required (ibid., 
42—44). The duties of the medical officer as to sick patients 
whose illness assumes a dangerous form, and in contagious 
cases and cases under punishment, have already been touched 
upon under the head of “ The Superintendent,” and see further 
M. R. 45—48. 

In case of illness or other cause of necessary absence the 
medical officer is to appoint a substitute approved of by the 
managers (ibid., 49). 

The Inspector .—The Secretary of State is empowered, with 
the consent of the Treasury in writing, to appoint inspectors 
of certified inebriate reformatories, and assign to them such 
•remuneration, out of money provided by Parliament, as the 
Treasury may determine (Act of 1898, sect. 7). In the 
meantime only one inspector—Dr. Branthwaite—has been 
appointed. 

Officers of the Reformatory .—Every officer is to be a total 
abstainer (M. R. 50), and any officer who is to the slightest 
extent under the influence of drink whilst in the execution of 
his duty is to be liable on conviction to a fine not exceeding 
£20, or to imprisonment, with or without hard labour, for not 

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1899-] 


BY A. WOOD RENTON. 


237 


more than three months {ibid., 60, v). Liability to a similar 
penalty is incurred by any officer who (i) mutinies or incites 
to mutiny ; (ii) violently assaults an inmate ; (iii) wilfully aids 
or permits an inmate to escape, or attempt to do so ; (iv) in¬ 
troduces or attempts to introduce intoxicating liquors into the 
reformatory {ibid., 60, i—iv). No officer is to receive any 
gratuity for the admission of visitors or patients on any pretext 
whatever {ibid., 31), or to strike a patient unless in self-defence 
{ibid., 56), and then, as in any other case where the application 
of force is needful, with no more force than necessary (57), 
or to inflict any punishment or privation on any inmate unless 
ordered by the superintendent (ibid., 58). Minor offences by 
officers are to be dealt with by the superintendent, under the 
orders of the manager (ibid., 59). Female inmates—a provision 
borrowed from the Lunacy Acts—are in all cases to be attended 
to by female officers, and a male officer is not to enter a re¬ 
formatory, or division of one, appropriated to females, except on 
duty, and accompanied by a female officer (ibid., 32). It should 
further be noted under this head that every officer authorised 
in writing by the managers to carry an inebriate to or from a 
reformatory, or to arrest him in case of escape, is to have all 
the powers, protections, and privileges of a constable (Act of 
1898, sect. 11 [1] ); and that any patient escaping from a re¬ 
formatory, or from the charge of the person in whose control he 
is placed under licence, may be apprehended without a warrant 
and brought back to the reformatory (ibid., 11 [2] ). 

Admissions, Discharge, and Removal. —As the judicial ma¬ 
chinery for the admission of patients to State Inebriate Re¬ 
formatories and Certified Inebriate Reformatories is the same, 
it will be more conveniently considered hereafter when we 
come to deal with the provisions equally applicable to these 
two classes of institutions. Here we are concerned with special 
administrative details alone. Every inmate, on admission, is 
to be separately examined by the medical officer, as above 
noted (M. R. 63), and is to have a bath, unless the super¬ 
intendent or medical officer otherwise directs (ibid., 64); and if 
he is found to have any cutaneous disease, or to be infested 
with vermin, means are to be taken effectually to eradicate the 
same (ibid., 65). Then follows a valuable provision, which has 
many analogues in American lunacy law. “ Chronic invalids 
incapable of earning their own livelihood, and persons who 

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238 


THE NEW INEBRIATES ACT, 


[April, 


require special care and constant medical attention, or persons 
suffering from any contagious or infectious disease, should not 
be eligible for an inebriate reformatory. Persons suffering 
from any organic disease in an advanced stage are not fit 
subjects for admission ; and in all cases of pulmonary tubercu¬ 
losis special precautions should be taken to prevent the com¬ 
munication of the disease to others ” (ibid., 66). Every inmate 
may also be searched on admission or subsequently, and all 
prohibited articles are to be taken from him (ibid., 61). All 
money or other effects brought into the reformatory by any 
inmate, or sent there for his use, which he is not allowed to 
retain, are to be placed in the custody of the superintendent, 
who is to keep an inventory of them in a separate book (ibid., 
62). No inmate is to be removed to any other reformatory or 
discharged without an examination by the medical officer; and 
prior to removal, or to the discharge at the expiration of his 
sentence, of a patient labouring under an acute or dangerous 
illness, the medical officer’s certificate of fitness is necessary 
(ibid., 67). Where a sentence expires on a Sunday, Christmas 
Day, or Good Friday, the discharge should be effected on the 
day preceding (ibid., 68). Discharge on licence (a form is 
given in M. R., App. Ill ; the licence should be granted by 
one or more of the managers on the recommendation of the 
superintendent and medical officer [M. R. 70] ) should be pos¬ 
sible after nine months’ treatment, and the rule after twelve. 
If an inmate is not licensed at the end of a year, the matter is 
to be reported to the Secretary of State ; if he is still in the 
reformatory at the end of eighteen months, there is to be a 
detailed report on the case. A temporary licence is to be 
given when any inmate is allowed to leave the reformatory for 
more than a few hours, either on business or on part of his 
probationary treatment (ibid., 69). A copy of every licence is 
to be sent to the police of the district in which the inmate is 
about to reside (ibid., 71). 

Food .—The prescribed dietary will be found in M. R., App. IV, 
which contains not only the ordinary diet, but the diet for ill- 
conducted patients. No substantial alteration is to be made 
in it without previous notice to the inspector, and all deductions 
from it are to be recorded. A copy of the dietary is to be hung 
in the dining-room or other public place (M. R. 72). The 
medical officer alone may permit any special addition to the 

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BY A. WOOD RENTON. 


239 


food in the diet scale in the case of a patient not being an 
inmate of the infirmary (M. R. 74). The inmates of the 
reformatory are to mess together, and the food is to be canned in 
the room, and not weighed out to each man. An inmate who 
has any complaint to make on the diet must make his request 
to an officer deputed -for the purpose as soon as possible after 
the diet is handed to him (M. R. 74). No intoxicating liquor 
or drug of any kind is to be admitted into the reformatory 
under any pretext whatever, except in pursuance of a written 
order of the medical officer specifying the quantity to be 
admitted, and the name of the name of the patient for whose 
use it is intended. This rule does not apply to the infirmary 
(M. R. 73). 

Clothing .—Each inmate is to be provided with a complete 
and suitable dress, and required to wear it, unless there are 
special reasons to the contrary ; however, a patient is to be 
allowed to use his own clothes if he desires (M. R. 76). There 
are further regulations imposed on patients—obligations as to 
cleanliness {ibid., 77), baths (ibid., 78), tidiness (ibid., 79) ; “any 
inmate may, however, if and on such conditions as the 
managers approve, employ another inmate as a servant to 
relieve him from the performance of any unaccustomed tasks 
or offices ” (ibid.) ; providing for the supply of sufficient clean 
bedding, with additions in cold weather or in special cases as 
the medical officer may deem requisite (ibid., 80) ; and pro¬ 
hibiting inmates from receiving clothing, bedding, or necessaries 
other than the allowance, except with the permission of the 
medical officer (ibid., 81). In the lunacy laws of several of the 
American States there is a provision that patients on discharge 
are to be supplied, if necessary, with clothing. It might be 
worthy of consideration whether a rule of this kind should not 
be incorporated in the regulations. 

Employment of Inmates. —App. V of the M. R. contains a 
model time-table of reformatory regimen, which may be repro¬ 
duced here, as it is quite short. 

Rise at 6 a.m.; breakfast, 7 a.m. ; physical drill (no fixed time)', 
chapel, 8.15; work, 8.30 till 11.30, compulsory; dinner, 
12 noon; work, 1.30 p.m. till 4.30, compulsory; tea, 5; 
recreation till bedtime ; inmates to go to bed at 9.30 p.m., 
lights out in day-room ; all lights out at 10 p.m. 

It will be noticed that (unlike the dietary sup.\ this is a 

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240 


THE NEW INEBRIATES ACT, 


[April, 


model, and not a prescribed form.. Whatever time-table is 
adopted, however, is to be approved by the Secretary of State, 
exhibited in conspicuous places, and strictly adhered to— 
occasional variations with the consent of the inspector being 
permissible (M. R. 82). On Sunday, Christmas Day, Good 
Friday, and fast or thanksgiving days the labour of an inmate 
is to be confined to what is strictly necessary for the service of 
the reformatory. It would be well if express provision were 
made for relaxations in favour of Roman Catholics and Angli¬ 
cans on other feast days than those above specified. A Roman 
Catholic or an Anglican cannot fairly be required to be engaged 
in “ compulsory ” work from 8.30 to 11.30 a.m. on say 
Ascension Day. Questions of this kind have occasioned con¬ 
siderable trouble in Board schools and workhouses during 
recent years, and there is all the less reason for any dubiety 
being left on the point that the rule above quoted is imme¬ 
diately followed by another (M. R. 84), that “ an inmate who 
is a Jew shall not be compelled to labour on his sabbath, or 
on such days of festival as may be prescribed.” Otherwise 
the regulations as to religious observances are of the usual 
character and quite unexceptionable (cf. M. R. 99—101): 
inmates are to be encouraged to do the kind of work, what¬ 
ever it be, for which their training and capacity suit them ; an 
accurate account of the earnings is to be kept, and assignment 
of the sums to be allotted (1) for maintenance, (2) to the 
inmate for his own use, and (3) to the inmate’s family or 
otherwise, is to be made in each case and notified to the inmate, 
who is to have a right of appeal to the Secretary of State. 
The scheme should specify what comforts (e.g. to have extra 
clothes, boots, &c.) may be purchased by an inmate from that 
part of the earnings assigned to himself (ibid,, 85). Provision 
is also made for chess, cards, &c. (M. R. 86), newspapers and 
magazines (ibid., 87), drill and outdoor games (ibid., 88), supply 
of books (ibid., 89), and inmates are to be allowed to receive 
works or periodicals from their friends if the superintendent is 
satisfied that they are of an unobjectionable nature (ibid., 90) 
and instructive (ibid., 91). 

Visits and Letters .—Visits to inmates are to be made within 
sight, but not (unless the superintendent orders it) within hearing 
of an officer (M. R. 92). The superintendent is to have power 
to remove from the premises (duly recording the fact in his 

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I8 9 9-] 


BY A. WOOD RENTON. 


24I 


journal) any visitor exercising a bad influence over a patient, &c. 
{ibid., 93). Permission may be given for Sunday visits in the 
case of friends who cannot come at other times {ibid., 94). 
Facilities are to be given to patients for seeing legal and busi¬ 
ness visitors {ibid., 95). The managers, when the circum¬ 
stances allow of it, may permit female inmates to have their 
infant children with them {ibid., 96). The powers of the 
superintendent as to letters have been noticed above (and see 
M. R. 97). Letters addressed to the Secretary of State or the 
inspector are to be forwarded unopened {ibid.). Inmates unless 
under punishment may receive and write letters as often as 
they desire, and receive a visit weekly, and the managers may 
allow any additional visits {ibid., 98). 

Mechanical Means of Restraint .— The strait-jacket alone is 
to be employed, and it is to be used only to prevent a patient 
from injuring himself or others. Particulars of every case of 
such use are to be entered in the superintendent’s journal. 
Notice is to be given forthwith to the managers; and no inmate 
is to be kept under mechanical restraint without the approval 
of the medical officer except in urgent cases, nor for longer 
than the medical officer thinks necessary. Every patient so 
restrained is to be seen by an officer at least every half-hour 
{ibid., 107). 

Punishments .—These are of two kinds : 

I. Dietary or other Restrictions or Deprivations of Privileges 
as set out in the rules (approved by the Secretary of State) for 
each reformatory (M. R. 102).—No such punishment is to be 
awarded except by the superintendent or the officer acting for 
him, nor until the accused has had an opportunity of hearing 
the charges and evidence against him, and of making his defence 
{ibid.). Dietary punishment is not to be inflicted on any inmate, 
nor is he to be placed in close confinement, unless on a certifi¬ 
cate of the medical officer that he is fit to undergo it {ibid., 1 06). 
The offences punishable in this way are disobedience (M. R. 103 
[1]), disrespect to an officer {ibid., 103 [2]), idleness {ibid., 
103 [3])—only, however, on a certificate by the medical officer 
of capacity to do the allotted work {ibid., 106),—absence without 
leave from {ibid., 103 [4]) or irreverence at {ibid., 103 [5]) 
divine service or prayers, cursing {ibid., 103 [6]) or indecency 
in language, act, or gesture {ibid., 103 [7]), making objection¬ 
able noises, giving unnecessary trouble, or making repeated 

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242 


THE NEW INEBRIATES ACT, 


[April, 


groundless complaints {ibid,, 103 [8]), disfiguring or injuring 
any part of the reformatory or any article {ibid., 103 [9]), com¬ 
mitting any nuisance {ibid., 103 [10]), possessing any prohibited 
article {ibid., 103 [11 ]), in any way offending against good order 
{ibid., 103 [12]), and attempting any of the foregoing offences. 

II. Punishment by a Court of Summary Jurisdiction. —The 
offences for which this may be inflicted are mutiny or inciting 
thereto (M. R. 104 [1]) personal violence to an officer or 
servant or fellow-inmate {ibid., 104 [2]), grossly offensive or 
threatening language to any officer or servant {ibid., 104 [3]), 
wilfully or wantonly breaking windows, &c., in the reformatory 
{ibid., 104 [4]), wilfully making serious disturbance while 
under punishment {ibid., 104 [5]), gross misconduct or in¬ 
subordination {ibid., 104 [6]), escaping or attempting to escape 
or aiding an escape {ibid., 104 [7]), introducing intoxicating 
liquors or drugs {ibid., 104 [8]), entering a public-house or 
taking any intoxicating liquor {ibid., 104 [9]), and serious or 
repeated offences under I, sup. (cf. 104, first par.). When 
any of these cases arise the superintendent is to report to 
the managers, who may (i) punish the offender by severer or 
longer continued restrictions in the reformatory, or (ii) prose¬ 
cute before a court of summary jurisdiction. Punishment: 
maximum penalty of £20, or three months 1 imprisonment with 
or without hard labour. In lieu of or in addition to any punish¬ 
ment, the managers may apply to the Secretary of State to 
transfer the inmate to another certified or State reformatory. 

The superintendent is to record details of punishments in the 
punishment book, and to remit them to the inspector for 
review. A supplementary Bill is to be passed this session 
dealing with the costs of prosecutions under these Rules. 

The chief provisions applicable to both State and Certified 
Inebriate Reformatories are the following: a county court 
judge may order the recovery of expenses against the estate of 
an inebriate whose real or personal property is more than 
sufficient to maintain his family (section 12 [1]), on the 
application {a) in the case of a patient detained in a State 
Inebriate Reformatory, of a person authorised for the purpose 
by the Secretary of State, and {b) in the case of a patient 
detained in a Certified Inebriate Reformatory, of the managers 
or any two of them or of any authority contributing to the 


maintenance of such patient (section 12 [2]). This section 


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243 


should be compared with sections 299, 300 of the Lunacy Act, 
1890 (see Wood Renton on Lunacy , ad be, ; section 1 of the 
Poor Removal Act, 1846 [by which as amended by the Poor 
Removal Act, 1861, and the Union Chargeability Act, 1865, 
a status of irremovability is acquired by one year’s residence 
in a parish, but it is provided that period of detention in a 
prison is not to count towards making up the year], is to apply 
to a person detained in or absent under licence from either a 
State Inebriate Reformatory or a Certified Inebriate Reforma¬ 
tory as if he were in prison [section 22] ). 

In addition to the provisions examined above, the Inebriates 
Act, 1898, creates fresh judicial powers for the treatment of 
criminal inebriates. The substance of the provisions is as 
follows : 

(1) Any habitual drunkard admitted by himself to be such 
or found by the jury so to be, may, if he be convicted on 
indictment of an offence and the Court is satisfied that the 
offence was committed under the influence of drink or that 
drunkenness was a contributing cause of the offence, be ordered 
by the Court, in addition to or substitution for any other 
sentence, to be detained for a maximum period of three years 
in any State or Certified Inebriate Reformatory, the managers 
of which are willing to receive him (section 1). Any habitual 
drunkard who is found drunk in any public place or who 
commits an offence against the Licensing and similar Acts 
(the Scots Departmental Committee, to whose valuable report 
reference is made below, point out [p. viii E.] that the list 
does not include the very common offence of breach of the 
peace committed while in a state of intoxication), after having 
within twelve months been convicted at least three times of a 
similar offence “ shall be liable upon conviction on indictment, 
or, if he consents to be dealt with summarily, on summary 
conviction to be similarly detained in any Certified Inebriate 
Reformatory” (section 2). As the Act of 1898 does not 
define “ habitual drunkard,” we are thrown back on the familiar 
definition in section 3 of the Act of 1879. 

“ A person who not being amenable to any jurisdiction in 
lunacy, is, notwithstanding, by reason of habitual intemperate 
drinking of intoxicating liquor, at times dangerous to himself 
or herself or incapable of managing himself or herself, and his 
or her affairs.” The following brief extracts from the Home 

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THE NEW INEBRIATES ACT, 


[April, 


Secretary’s recent (see Law Journal , February 4th, 1899) cir¬ 
cular letter to Judges, Chairmen of Quarter Sessions, and 
Recorders, shows the official view of the object and working of 
these important sections. 

I may, perhaps, without impropriety, call to your mind that the system of refor¬ 
matory treatment instituted by the new Act is designed by Parliament to replace 
the system of fines or short sentences of imprisonment which has hitherto been the 
only means possessed by Courts of Summary jurisdiction for dealing with the 
offences of drunkenness set out in the first schedule of the Act, and which has 
been found so ineffectual in the case of confirmed drunkards. You will observe that 
under the Act you have power to order an inebriate qualified thereunder to be 
detained for as long a period as three years. There would appear to be a consensus 
of opinion among medical men and otners experienced in the treatment of inebriates 
that in order to give a chance of effective operation to even the best designed 
method of reformatory treatment a considerable period of detention, amounting in 
most cases to at least a year, is essential. It is found that detention for short 
periods, such as three, six, or nine months, almost invariably proves ineffectual in 
securing the desired reformation. 

It is accordingly anticipated that, save in very exceptional cases, it will not be 
deemed expedient to commit inebriates to reformatories for such short periods. 
You will observe that the regulations, which will be carried out under close Govern¬ 
ment inspection, provide that detention in those institutions shall not be of a 
punitive but entirely of a reformatory character, and that a system of licensing or 
probationary discharge will be brought into operation as early in each case as the 
circumstances will allow. 

Accordingly, in view of the absence of all harshness, from the discipline to be 
maintained, there would seem to be no objection to committals, in appropriate 
cases, for the full period allowed by the Act. I am advised that the reformatory 
treatment to be carried on in the institution, followed, as it must be, by a term of 
probationary freedom under licence, cannot be successfully carried through under 
eighteen months to two years, even in favourable cases. 

The other class of offenders who come within the reformatory provisions of the 
Act are persons convicted on indictment of an offence punishable with penal 
servitude or imprisonment, when the Court is satisfied that the offence was com¬ 
mitted under the influence of drink or that drunkenness was a contributing cause 
of the offence, and when the jury finds that the offender is an habitual drunkard. 

Such persons may be sent, for a term not exceeding three years, either to one 
of the certified rerfomatories already described, or to a State reformatory; and the 
committal to a reformatory may be either in addition to or in substitution for any 
other sentence. 

In conclusion we must notice the adaptations of the Act of 
1898 to Scotland and Ireland. 

Scotland ’—The provisions as to the committal of inebriates 
are adjusted to Scottish criminal procedure by sections 23 and 
24. The Secretary for Scotland takes the place of the Secretary 
of State (section 2 5 [a] ). The person vested with the title to 
any available poorhouse, may with the consent of the Scottish 
Secretary give the use of it for the purposes of an Inebriate 
Reformatory (ibid, [b] ). For Prisons Acts, 1863—98, read 
Prisons (Scotland) Act, 1877 (ibid, [c] ). For references to a 
borough and the borough council shall be substituted reference 
to a burgh and the town council thereof, “ burgh ” shall include 

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BY A. WOOD RENTON. 


245 


police burgh, and “ town council ” shall include burgh commis¬ 
sioners, and “ town clerk ” shall include clerk of the burgh 
commissioners {ibid, [d] ). For the purpose of raising money 
by rate or loan in order to defray expenditure under this Act, 
county councils and town councils shall have the same powers 
as if a certified inebriate reformatory were a certified refor¬ 
matory within the meaning of the Reformatory Schools Act, 
1866 (ibid, [e] ). The reference to the Poor Removal Act, 
1846, shall not apply, but in any computation of time for the 
purpose of ascertaining the settlement of any pauper, the time 
during which he has been detained in an inebriate reformatory 
shall be reckoned as time spent by him as a prisoner (ibid. [ /] ). 
References to a county court judge mean to the sheriff, those to the 
coroner shall be construed as references to the procurator fiscal; 
and references to the London Gazette shall be construed as 
references to the Edinburgh Gazette (ibid, [g] ). 

The English Reports and Regulations should also be com¬ 
pared with the extremely valuable Report of the Departmental 
Committee appointed by the Secretary for Scotland to consider 
the Act from the Scottish point of view. The Committee con¬ 
sisted of Lord Overtoun, Mr. W. C. Dunbar, Lieutenant-Colonel 
McHardy, Mr. Dove Wilson, and Miss Flora Stevenson, and 
Dr. Clouston. In the main, the recommendations and draft 
rules are similar to, though much fuller than, those of recent 
English committees. The introductory report is a contribution 
of permanent value to the medico-legal literature of inebriety. 

Ireland. —For Summary Jurisdiction Act, 1879, read Criminal 
Justice Act, 1855 (section 26 [a] ). The establishment of State 
Inebriate Reformatories rests with the Lord Lieutenant, with 
the approval of the Treasury, and through the agency of the 
Prisons Board (ibid. [b]). Read for the Prisons Acts, 1865— 
98, the Prisons (Ireland) Acts, 1826—84 (ibid, [d]) ; for a 
borough—county borough, and for county council—council of 
a county borough (ibid, [e] ) ; as to borrowing powers see ibid. 
(f ) ; for London Gazette , Dublin Gazette (ibid, [h] ). The Poor 
Removal Act, 1846, does not apply (ibid. [*]). Ireland was 
excluded from Sir Matthew White Ridley’s Bill as printed on 
April 21st, 1898 (see Bill 187, clause 26). 


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246 


CASE OF IMPERFECT PORENCEPHALY, 


[April, 


A Case of Imperfect Porencephaly , reported by T. Aldous 
Clinch, M.D., Pathologist, Durham County Asylum.( l ) 

A COMPLETE microscopical examination of the following case 
was made with the hope that new light might be thrown not 
only on the pathology of the disease itself but also on some of 
the disputed points of cerebral anatomy. 

History .—The child, a male, was bom after a long and 
tedious confinement, forceps being used finally, and the head 
much crushed and grazed by them. Till eleven months old 
development proceeded normally, but at this age, while being 
bathed one day, there were convulsive movements of the right 
side ; from this time on, the right side was observed to be 
weaker than the left; for example, if when crawling he fell, he 
was unable to rise. He commenced to walk at the age of 
eighteen or nineteen months, about three or four months later 
than his brothers and sisters. He commenced to speak about 
the same age as they did, namely, when two years old. The 
next fit that was observed occurred when he was three years 
old ; it was apparently purely of a tonic kind, and no clonic 
movements are described ; it lasted for two or three hours, 
during which he was unconscious, afterwards he was weak and 
confused. He went on well till he was nine years old, when he 
had a whirling fit. Three months later the first fit of the ordinary 
kind occurred ; they became more frequent till they amounted 
to several a week. 

At the age of seventeen he was admitted to the Durham 
County Asylum on account of attacks of violent mania. 

On admission .—Patient is an undersized lad with marked 
right hemiparesis ; the arm is drawn to the side, the elbow sub¬ 
luxated and flexed, the forearm pronated, and the wrist and 
fingers flexed. The thigh is slightly flexed and adducted, the 
knee is also flexed slightly, and the ankle is extended. The 
affected side is colder and smaller than the other, and its move¬ 
ments are limited ; for instance, if the patient uses his right 
hand at all it is only the two outer fingers, which he can move 
Voluntarily ; reflexes exaggerated. 

Mentally he was epileptic, suicidal, and dangerous, to others ; 

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BY T. ALDOUS CLINCH, M.D. 


247 


he could speak plainly and naturally, was able to write a little 
with the left hand ; his intellect was that of a high grade 
imbecile. 

Ten months after admission he suffered from status epilep- 
ticus of several hours’ duration. Two years and a half after 
admission he died from typhoid fever. 

Post-mortem Report ,—Right lower limb, 71*5 cm. long ; left, 
73*5 cm. long. Right upper limb, 31 cm. long; left, 32 cm. 
long. Girth of right thigh, 29 cm.; left thigh, 32 cm. Girth 
of right upper arm, 21 cm. ; left upper arm, 24 cm. 

Head ,—The scalp is thick ; skull-cap thin and very asymme¬ 
trical (unfortunately I have no tracings). The right half is 
larger than the left, and the left thicker that the right. 

Dura mater ,—Nothing special; sinuses are empty. Pacchio¬ 
nian bodies well marked, adhering extensively to the dura. On 
removing this a very notable disproportion is seen between the 
two sides of the brain, the right side being the larger. On pal¬ 
pation this side has the ordinary consistence, while the left side 
is hardened. At the lower end of the fissure of Rolando, left 
side, is a translucent-looking patch in the membranes about the 
size of a sixpence, which is found to be part of the outer wall 
of a cyst of considerable size which lay in the corona radiata. 

Around this cavity the convolutions were exceedingly atrophied, 
narrowed, and hardened (microgyria); they were the lower third 
of the two central gyri, the supra-marginal, and part of the 
angular and of the first temporo-sphenoidal gyri, the whole of 
the convolutions of the island of Reil (obliterated), and the 
posterior half of the third frontal, including Broca’s convolution. 
The cavity was oblong, the long diameter from before back¬ 
ward 6 cm., transverse diameter 2 cm. There are a few 
imperfect cicatricial septa. The cavity was lined outside by 
the arachnoid and internally by the pia mater. 

The soft membranes strip readily from both hemispheres. 
On separating the hemispheres the corpus callosum is seen to 
be small and atrophic, especially in its third (from before back¬ 
wards) quarter; the fornix is found to be drawn over to the 
left so that its central part escapes division by the knife. Dis¬ 
section of the right hemisphere reveals no recognisable devia¬ 
tions from the normal. 

The cerebellum is symmetrical, each side weighing two and 
a half ounces. The crura, pons, medulla, an|l cord| are all 

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248 


CASE OF IMPERFECT PORENCEPHALY, 


[April, 


smaller on the left side ; the spinal cord is smaller on the right. 
The other organs presented lesions characteristic of the end of 
the second stage of typhoid fever. Here it will be convenient 
to refer to a change in the cells of the cord which relates to the 
febrile disease and not to the nervous disease. These cells, 
whether stained by Nissl’s method or haematoxylin in different 
ways, show none of the structure which is their normal character¬ 
istic. The stain is always diffuse. Unna’s polychrome methy¬ 
lene blue method will be described in the next number of this 
Journal. 

The left hemisphere, crura, pons, medulla, and cord were 
hardened in formalin 10 per cent. Sections were made by the 
freezing method from several segments of the cord, but the other 
tissues were embedded in celloidin and cut on the sliding 
microtome. 

Sections stained by haematoxylin and eosine, the Weigert- 
Pal method, Nissl’s method, and the silver chrome method 
(modifications being employed as previously detailed). (*) 

For magnification with high powers, small pieces of the left 
hemisphere were taken from the microgyres and from the more 
normal parts of the left hemisphere. 

In the centres and frequently at the bases of these sclerosed 
gyri are cyst-like spaces of some size, though the walls, as a 
general rule, are but slightly separated. 

These spaces contain delicate connective tissue of the ordi¬ 
nary type, and distended blood-vessels with thin walls. They 
have no lining membrane, but the connective tissue becomes 
dense, and is finally backed up by a close feltwork of neu¬ 
roglia. 

Dr. Campbell Clarke,( s ) in 1879, published a case in which 
he described appearances which he thought proved the exist¬ 
ence of intra-gyral systems ; and in the case before us there are 
appearances which bear a strong resemblance to Dr. Clarke’s 
figures, but perhaps I shall not be accused of captiousness if I 
say that modem methods and instruments force one to a con¬ 
clusion at variance with his. In a haematoxylin and eosine 
preparation these fibres take on the vigorous eosine stain of 
connective tissue ; they are coarser than axis-cylinders and more 
irregular in their appearance ; they show no myelin with the 
Weigert-Pal stain. They are arranged in coarse bundles, in a 
few instances appear • to be continuous with the delicate tissue 

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BY T. ALDOUS CLINCH, M.D. 


249 


contained in the cystic spaces, the fibres as they pass into the 
space becoming more filmy and more loosely arranged. The 
bundles start a short distance from the surface, and course in¬ 
wards or outwards, becoming rapidly smaller and then expand¬ 
ing again at the level of the cysts or on the surface of the con¬ 
volution. When two or three are associated together there is 
a marked puckering of the convolution at that spot. At the 
commencement of each fibre is a nucleus, and this collection of 
nuclei and the peculiar shape of the bundle gives rise to a 
peculiar “wheat-sheaf” appearance. The general ground tissue 
consists of a close neuroglia network dotted with nuclei. Where 
these bundles are present I have never been able to find nerve- 
cells. 

In an earlier stage of the sclerosis, the bundles of nerve-fibres 
passing from the cortex become looped, and produce an appear¬ 
ance like honeycomb ; they are very delicate, and the myelin is 
collected in small droplets along the axis-cylinders. Where 
fibres pass to a band of more extreme sclerosis they become 
much coarser; the myelin is in large droplets at some distance 
apart ; the coarseness of the fibres excels that of any others I 
have ever seen. 

The progress of the disease appears to be as follows : the 
original attack, whatever its nature, has produced necrotic 
changes in the adjacent cortex ; this has been invaded by cells 
from the pia mater or from the blood-vessels ; these cells 
organising, contract and drag the nervous tissue where it still 
exists out of its proper course and relationships. This tissue 
gradually dies, and is replaced by true neuroglia or by the 
invading connective tissue. In time the connective tissue 
degenerates, and so cavity formation is produced. It may be 
mentioned that there are parts of this sclerosed cortex which 
show a gradual thinning out of the connective tissue, which 
begins to assume the characters of that in the spaces. It will 
readily be seen, therefore, that this is a process which differs 
altogether from the ordinary sclerosis of nervous tissue. 

The silver chrome preparations show splendid neuroglia 
cells in the white matter, but a smaller proportion in the grey. 
The nerve-cells are very sparse, and are all fusiform and at¬ 
tenuated ; their processes are few and devoid of thorns. I have 
never been able to trace the apical process into the first layer, 
and there appear to be no cells with an ascending cylinder 

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CASE OF IMPERFECT PORENCEPHALY, 


[April, 


axis. In sections from the frontal lobe where the convolutions 
are not shrunken in appearance but are hard (as is the whole 
hemisphere), the neuroglia cells stain predominantly, and the 
nerve-cells are in the main fusiform, though a very few show 
the classical outline even if somewhat attenuated. Their basal 
processes are few and small and devoid of thorns. The apical 
processes have an appearance as if their tip had been sat on, 
and the process had as a result assumed an irregular spiral 
appearance. 

Nissl and haematoxylin preparations show more cells of ap¬ 
proximately normal appearance, but an enormous number of 
fusiform cells. 

The left hemisphere having been hardened entire, was em¬ 
bedded in celloidin, and cut in a coronal direction from the 
occiput to the frontal region. A few sections were stained by 
haematoxylin, but the great bulk by the Weigert-Pal method. 
The sections as cut were placed in the mordant, and it is note¬ 
worthy that those stained in the first two months show much 
more accuracy in the details as demonstrated by high powers, 
than those stained later. After the sections were stained they 
were dehydrated, counterstained with eosin, cleared in a mixture 
of creosote and xylol (equal parts), and mounted in balsam. It 
was found that Weigert’s mixture of xylol and phenol appre¬ 
ciably reduced the vigour of the haematoxylin stain. After 
some search the above mixture was found successful ; it does 
not attack celloidin, clears rapidly, but does not remove aniline 
dyes rapidly. 

It was hoped, perhaps foolishly, that specimens prepared in 
this way would reveal tracts of sclerosis, and so perhaps throw 
light on some points of brain anatomy ; it must be confessed, 
however, that the results attained have not come up to expecta¬ 
tion. The fresh brain was markedly hardened to the touch, 
and corresponding with this is found microscopically a diffuse 
sclerosis, in which certain bands of fibres stand out in marked 
relief, but whether more or less well marked than in a normal 
one my experience does not enable me to say. It will be best, 
perhaps, to take the different tracts as shown in the specimens, 
considering each briefly. (The method of description bears no 
relation to the direction of the nervous impulses.) 

Tracts as seen in a Section in the Posterior Part of the Ascend¬ 
ing Frontal Convolution. —From the vertex running in the plane 

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BY T. ALDOUS CLINCH, M.D. 


251 


of the section, descending fibres pass downwards and forwards, 
gradually collecting together to form a well-marked bundle in 
the middle of the white matter (Tract A). This bundle just 
above the middle of the callosal gyrus meets another arched 
tract, to be described further on. A few fibres on both outer 
and inner side pass into this arched bundle, but the vast majo¬ 
rity pass through it and appear on its under side. Here, not in 
bundles, but fibre by fibre, they turn sharply at right angles, 
and passing inwards and downwards, enter the corpus callosum. 
A few fibres relatively pass on and enter the plexiform nucleus 
(of Hamilton). ( 4 ) Homologous with these fibres are some which, 
starting from the convolution immediately above the “ porus,” 
or rather cavity, pass horizontally inwards, cutting the outer 
limb of the arched bundle, bend slightly downwards and then 
at right angles, and join the fibres of Tract A which enter the 
corpus callosum (Tract B). Parallel with Tract A is another 
(Tract C), which becomes better marked as we pass forward ; 
arising from the same area as the first, it passes to its outside, 
and after bending like an elbow into the base of the convolution 
from which Tract B originated, divides into two bundles, one 
of which passes into the internal capsule and is most marked 
anteriorly, while the other passes into the external capsule and 
is most marked posteriorly. Many of the fibres of this latter 
bundle can be traced into tracts which pierce the lenticular 
nucleus, and may possibly penetrate to the internal capsule. 

The fibres from the internal capsule pass forwards and 
upwards, thus being cut obliquely (the plane of section being 
downwards and slightly forwards). The bundle inclines inwards 
till the centre of the white matter is reached, when, still getting 
smaller, it bends inwards and downwards, finally, at the level of 
the middle of the callosal convolution, almost disappearing as a 
distinct entity to the naked eye. A short distance further on 
it is met by the fibres of the corpus callosum. Both from its 
outer and inner surface fibres are given off freely, in an upward 
direction, to the general mass of white matter ; they can be 
distinguished from bundle A in that they are coursing forwards 
as well as upwards, their length visible in one section being cor¬ 
respondingly short The mass of the fibres belonging to this 
tract, the crossed callosal of Hamilton,( 4 ) are collected in 
bundles which interlace in so complex a manner that it is 
impossible from the microscopical sections (cut as in this case) 

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252 


CASE OF IMPERFECT PORENCEPHALY, 


[April, 


to say whether or not these bundles run from the internal 
capsule to the corpus callosum ; to the naked eye many 
apparently do so. At the level of the anterior end of the 
optic thalamus a small bundle of fibres (Tract E) is split off 
the issuing part of the internal capsule ; the majority of its 
fibres pass upwards, but a small proportion bend toward the 
main tract, curving round outside it and finally blending with it. 

At the level of the genu corporis callosi, the crossed callosal 
tract is represented by a few fibres only, while the motor fibres 
mingled with it pass from its apex in a bundle parallel with 
Tract C. Anterior to the corpus callosum, these two tracts run 
in a sagittal direction forwards, their upper and lower fibres 
spraying off gradually to the adjacent convolutions. 

From the corpus callosum comes a tract (D) of very fine fibres, 
which stain a brownish tint in contrast to the blue tint of the 
others; these fibres, which are distinctly medullated, pass beneath 
the bend of the crossed callosal tract among the fibres of Tract A 
(already turned at right angles) to the vertical part of the 
crossed callosal, where they bend obliquely downwards and 
mingle with its bundles ; characterised by their brown colour 
and their delicacy, they can be traced through them, and are 
seen to pass into the external capsule. That many fibres bend 
more and enter the internal capsule is very probable, but a 
definite statement to this effect cannot be made. 

Areas of Sclerosis in the White Matter .—Immediately to the 
outer side of the vertical part of the crossed callosal tract is an 
area of sclerosis of triangular shape, which separates this crossed 
callosal tract from Tract C. Its upper horizontal border is 
formed by the horizontal fibres of Tract B. From this upper 
end extends far into the upper part of the hemisphere an area 
in which are no fibres with a vertical direction. It may be 
assumed, therefore, that this area (small in transverse section, 
but long in an antero-posterior direction) has interrupted fibres 
which pass from the external capsule to the upper and outer 
convolutions. In the external capsule are frequently small 
areas which are unstained in the Weigert-Pal preparations, and 
in which no nerve-cells can be seen in the haematoxylin ones, 
so that it may be assumed that these are also sclerotic areas, 
and not, as might possibly be thought, parts of the claustrum ; 
this structure appears to be either entirely undeveloped or 
entirely destroyed, for no traces of it are visible.* In the 

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BY T. ALDOUS CLINCH, M.D. 


1899.] 


253 


basal ganglia no appearances worthy of special note were to be 
found. 

The fornix, as has already been said, has been drawn over tb 
the left side, and its left half is much smaller than its right. 
There is in it also excessive development of connective tissue. 
At its posterior end it is completely united to the corpus 
callosum, but anteriorly it is divided from it by a narrow band 
of connective tissue. Throughout its length vertical fibres pass 
freely from one to the other. 

The sections through the crura and pons show an extremely 
marked asymmetry, which applies more or less to nearly all the 
structures, those in which it is least marked being the superior 
peduncles of the cerebellum, the nuclei and roots of the cranial 
nerves, and the posterior longitudinal bundles ; those in which 
it is most marked being the vertical fibres, both motor and sen¬ 
sory, and the transverse bundles. 

In the medulla we find the same asymmetry, but here it is 
most severely marked in the pyramids, the left one being exceed¬ 
ingly small. At the internal angle of each pyramid is a small 
group of nerve-cells, which to some extent insinuate themselves 
between the adjacent fibres ; these nuclei, described variously 
as the pyramidal nuclei of Stilling or as the nuclei arcuati, are 
not described or mentioned in one prominent text-book at least. 
In the present case they are unequal in size, that on the left 
side being the larger ; we find in the spinal cord that the 
anterior horn on the smaller side (the right) is larger than its 
fellow. 

In the spinal cord the asymmetry is much less obvious than 
in the parts already described ; it occupies the classical posi¬ 
tions of the two pairs of pyramidal tracts, and in the crossed 
pyramidal tract can be traced the whole length of the cord, but 
in the direct only to the earlier dorsal. 

The affected pyramidal tracts throughout their length show 
a slight degree of sclerosis, a fact in opposition apparently to 
those who consider the direct tract arises inferiorly to the cor¬ 
tex.^) There is also in them a higher proportion of fine 
fibres ; as already said, the anterior horns are larger on the 
affected side, and counting over a number of sections, the cells 
there are found to be distinctly greater in number. The pos¬ 
terior columns are equal in size and normal in appearance. 


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CASE OF IMPERFECT PORENCEPHALY, 


[April, 


General Conclusions . 

I have no intention of making this case the text for a dis¬ 
cussion on porencephaly, but merely to refer as briefly as 
possible to the principal points in connection with it. Those 
who wish to study the literature will find a very complete 
bibliography given with the case reported by Dr. Conolly 
Norman and Professor Alec Fraser.( 6 ) 

The Primary Pathological Condition .—The most frequent 
causes are haemorrhage and arterial obstruction ; in favour of 
the former we have the conditions of his birth, the situation of 
the lesion, which, although over the area of distribution of the 
Sylvian artery, is not co-extensive with the whole artery or 
any one of its branches, the absence of cause for thrombosis or 
embolism, apd its relatively greater frequency ; in favour of the 
latter is the onset of convulsions without an apoplectiform 
attack, and the delay in the appearance of the fits. If we accept 
haemorrhage as the cause, then the moment of birth appears the 
most probable time for dating the injury, and I think the time of 
appearance of convulsions nine months later is not altogether 
incompatible with this idea. It may be noted that medullation 
of the pyramidal tracts in the cord is complete at birth, whereas 
higher up it is not complete till somewhat later. Now in all 
probability cicatricial processes in the cortex would prevent 
medullation of the tracts originating there, while the other 
cerebral tracts in communication with it, but not medul- 
lated till much later, would not be affected by the irritation till 
their structure was perfect. An excess of peripheral irritation, 
a shock in fact, is produced by a bath, and a spreading uncon¬ 
trolled stimulation extends itself over the whole cortex. 

Kundrat ( 7 ) pointed out that intra-uterine cases show a 
radial arrangement of the convolutions around the diseased 
area, and Gierlich showed that in infantile cerebral paralysis no 
secondary degeneration was found. In a case published by 
Drs. Wiglesworth and A. W. Campbell, (*) which was supposed 
to be due to traumatism at birth, there was very severe sclerosis 
of the pyramidal tracts of the cord, with none above the decus¬ 
sation ; and in another case published at the same time there 
was neither hemiatrophy nor hemisclerosis of the brain-stem, or 

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JOURNAL OF MENTAL SCIENCE, APRIL, 1899. 


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255 


cord, whilst the cerebellum was asymmetric. This case was 
probably partly due to developmental defect, and partly to 
softening (intra-uterine). Thus there may be several different 
results arising from closely allied conditions, and it would be 
injudicious to draw conclusions as to the date of injury to the 
brain from the state of the lower part. 

The Crossed Callosal Tracts .—From the study of cases such 
as these it appears probable that in addition to the tracts 
ascending from the basal ganglia to the cortex of the opposite 
side through the corpus callosum, the existence of which has 
been proved by Ferrier and Turner, ( 9 ) there are other descend¬ 
ing motor fibres that take this course. The histological exami¬ 
nation has not definitely proved the existence of any large 
mass of these fibres, but many fibres can be seen which certainly 
give the impression that they take this course, though the 
direction of their impulses is of course unknown (the fibres 
passing from tract E round the crossed callosal of Hamilton, 
and finally mingling with it, for instance). 

The corpus callosum in its third quarter is more atrophied 
than elsewhere, so perhaps one may associate this portion 
more especially with the area of disease. 

The Spasm of the Affected Side .—Charcot formulated the 
theory that in ordinary hemiplegia occurring in the adult the 
cause of the late rigidity is the irritation of the motor tracts by 
the cicatrisation that occurs at the seat of lesion and extends 
along them. Others have shown that complete division of the 
cord causes loss of reflexes below the section, and that not till 
some time after are they regained, when they become exagge¬ 
rated. In our case (as is usual in such cases) we are confronted 
by spasm of the vaso-motor as well as of the voluntary 
muscles, together with lowered nutrition, though the degree of 
sclerosis is very slight; in other cases the same conditions 
occur and yet no sclerosis at all is present. If, as is more than 
probable, the few cortical fibres that reach the cord come from 
parts of the hemisphere not directly affected, there is little 
reason for supposing irritation of importance passes from the 
cerebrum to the cord, and we must fall back on the theory that 
the spastic condition is the result of over-action of the cells of 
the anterior cornu unrestrained by inhibiting cortical influences. 
It may be said the whole cortex is sclerosed to a greater or 
less extent, and this is true in this case, but not in all, and not in 

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256 CASK OF IMPERFECT PORENCEPHALY, [April, 

this in its earlier stages, when the conditions referred to were 
already marked. 

(*) Read at the Annual Meeting of the Association, Edinburgh, July, 1898.— 
( a ) 44 A Case of Chorea Gravis,” Journ. Ment. Sci., Oct., 1898.—(*) “ A Detached 
Left Occipital Lobe and other Abnormalities in the Brain of a Hydrocephalic 
Imbecile,” by A. Campbell Clarke, M.B., Journ. Ment. Set., Oct., 1879, xxv.— 

( 4 ) 44 Remarks on the Conducting Paths between jhe Cortex of the Brain and the 
Lower Centres,” by D. T. Hamilton, M.D., Brit. Med. Journ., 1887, vol. i, p. 493.— 

( 5 ) 44 On the Tracts of the Spinal Cord and their Degenerations,” by A. W. Camp¬ 
bell, M.D., Brain, No. 80, vol. xx.—( a ) 44 A Case of Porencephaly,” by Conolly 
Norman, F.R.C.P.I., and Prof. Alex. Fraser, Journ. Ment. Sci., Oct., 1894.—( 7 ) Die 
Porencephalic , eine anatomische Studie, Graz, 1882, by Kundrat.—( 8 ) 44 Two Cases 
of Porencephaly,” by J.Wiglesworth, M.D., Brain, Nos. 77 and 78, vol. xx.—(•) “ An 
Experimental Research upon Cerebro-cortical Afferent and Efferent X rac t s »” by D. 
Ferrier, M.D., F.R.S., and W. A. Turner, M.D., F.R.C.P., Phil. Trans. Roy. Soc., 
1898. 

Illustrations. 

1. —External view of left hemisphere (membranes stripped). Natural size. 

2. —Internal view of left hemisphere (membranes stripped). Natural size. 

The lines indicate the original pieces into which the brain was cut, and also the 
general direction of the sections. 

3. —Section from the occipital region posterior to the corpus callosum (through 
the middle of the second piece). 

4. —Through the middle of the internal capsule and crus, showing an apparent 
crossed callosal tract very strongly marked (through the middle of the third piece). 

5. —Through the anterior part of the optic thalamus. The apparent crossed 
callosal tract is now much smaller, and beneath it can be seen the fibres described 
as tract D in the text (through the anterior part of the third piece). 

6. —Section immediately posterior to the foramen of Monro, showing tract C as 
a well-marked bundle. 

7. —Through the genu corporis callosi, showing the two tracts running forwards 
(C and motor tract M). 

Figs. 3, 4, 5, and 6 show the sections as seen from before backwards. Fig. 7 
shows the section from behind forwards. These figures are all taken from the 
actual specimen by direct contact. They show the cavitation which has occurred 
in the sclerosed gyri with distinctness. 

8—12. —Diagrams showing the various tracts as described in the text. The 
lettering corresponds with that. In addition : M.*«motor fibres; I.As.**intra-gyral 
association fibres; Cr.Cl.**crossed callosal tract; A.P. = ansa peduncularis; C.F.* 
fibres passing between the corpus callosum and the fornix; L.N. — Lenticular nucleus; 
C.N. — caudate nucleus; O.T.»optic thalamus. 

13. —Section through the pons, x 2. 

14. — „ the medulla oblongata, x 2. 

15. — „ the spinal cord, cervical region, x 2. 

16. — „ „ lower lumbar region, x 3. 

17. — „ „ „ sacral region, x 3. 

In Fig. 15 the crossed pyramidal tract is readily seen to be lightly sclerosed on 
the atrophied side. The direct tract is atrophied, especially posteriorly, where it is 
best marked in this part of the cord. 


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JOURNAL OF MENTAL SCIENCE, APRIL, 1899 . 



Fig. 15. 



Fig. 16. 


















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SCIENTIFIC PSYCHOLOGY. 


257 


On the Bases and Possibilities of a Scientific Psychology 
and Classification in Mental Disease . By W. Lloyd 

Andriezen, M.D.Lond. 

Part I. 

Since the middle of the nineteenth century psychology has 
gradually come to be recognised as a branch of biological 
science. This is due to the influence of the works of Darwin 
and Herbert Spencer, of the Clinical and Neurological School 
of Meynert, Golgi, Cajal, Flechsig, and others, and recent 
developments in the Psychometric School of Fechner and 
Wundt on the other. The Alienistic School can render power¬ 
ful aid to this movement; and though there are indications of 
the current in the proper direction, as shown more particularly 
in the wQrk of Mercier (1) and Bevan Lewis (2), the end, however, 
cannot as yet be said to have been achieved, nor the movement 
to have become general. Psychology still lingers on the bor¬ 
derland of metaphysics ; it has not yet been established on the 
firm rock of natural science. And while it thus lingers pro¬ 
gress in knowledge is slow and restricted. 

Consciousness generally .—Of consciousness in the abstract, 
and apart from the individual being or organism which manifests 
(and experiences) it, we know nothing. It is a subject for 
metaphysical speculation, and is transcendental. Griesinger well 
said that “ the pathway to psychiatry is not through the dark 
portals of metaphysics. ,, 

Consciousness in the widest sense (3) may be spoken of as an 
endowment of the entire living organism, and therefore specific¬ 
ally associated also with its several parts ; in the stricter sense 
we shall, however, find that in accordance with the principle of 
differentiation of structure and division of labour, which is such 
a striking feature throughout the living world, its special seat 
is in, and its manifestations proceed from, the nervous system. 

The Seat of Consciousness, —For if there be any special organ 
(or organs) of consciousness in the organism, clearly it must be 
in (and must constitute) a region (a) in which all impressions 
from the environment, acting on the organism, would arrive and 
be duly received ; it would also be a region ( b ) from which out- 

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SCIENTIFIC PSYCHOLOGY, 


[April, 


going stimuli or responses would start (in response to the 
previously received impressions), to bring about or determine 
appropriate reactions of the organism. Further, it must of 
necessity be (at least in all the higher animals whose life is 
more than ephemeral) a region (c) in which the returning cycle 
of impressions from those parts of the organism which have 
reacted, or are still reacting, would arrive and be also registered ; 
so that the central organ is now made conscious or aware of 
the fact that the appropriate reactions have been or are being 
accomplished. These facts further necessitate various complex 
centres and pathways which must of necessity subserve the 
above outlined complex activities of the organism, and point 
to the fact that fundamentally the constitution of the whole 
organ of consciousness must be (in its simplest form) three¬ 
fold. 

Its Constitution and Complexity .—Such is the simplest and 
yet most comprehensive way of regarding the organ of con¬ 
sciousness ; and this exists in the central nervous system, which 
is the aggregate organ and centre of consciousness—the central 
feeling-and-responding mechanism of the entire organism. 
Further anatomical and pysiological evidences need not detain 
us. The fundamental fact being established, it remains for us 
to study the phenomena of consciousness—the work of 
psychology. 

Methods of Study .—( a ) Self observation. This includes intro¬ 
spection, individual experience, and auto-experimentation. ( b) 
Observations and studies on our fellows in healthy conditions 
and the normal state ( normal psychology ). Such observa¬ 
tions, to be of real value, must take into account differences of 
age, temperament, race, and social environment, if) The 
special study, observation, life-history, and collateral investi¬ 
gation of those who are the subjects of mental (psychical) 
diseases, disorders, and alienations generally ( psycho-pathology), 
{d) Systematic observations on the growth, development, and 
other phases (including all impulses, passions, instincts, propen¬ 
sities, &c.) of the mind and life of infants and children, and 
including pubescents and adolescents of both sexes ( psycho¬ 
genesis ). An adequate and consistent psychology must take 
into account all these four methods and sources of knowledge. 

When data from these sources are carefully and critically 
gathered, collated, studied, and formulated into generalisations 

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1899,] BY W. LLOYD ANDRIEZEN, M.D.LOND. 2 59 

or “ laws,” then psychology is raised to the dignity and worth 
of a science ; otherwise it is a mass of empiricisms, a labyrinth 
of confusion. 

The Older Belief (. Metaphysical ).—Early psychologists spent 
their time in discussing the nature of the soul, of spirit, and their 
relation to the body. The mind was by some regarded as a 
portion of the soul; others held that the two were one and 
indivisible; some, however, postulated a higher essence or 
entity within the soul itself—the spirit. Such conceptions were 
natural to the childhood of the world. Death focussed the 
popular mind upon the unknown. Men saw that in death— 
unlike in sleep, where breathing was still maintained—the corpse 
ceased to breathe, and became cold and stiff, and that it finally 
decomposed and disintegrated. What more probable than that 
the breath was the soul\ or animating principle , or essence of life ; 
and that the condition of death was simply the departure of 
this caged breath ?(4) 

Crude Theories of Soul ’—This crude naturalism is an indica¬ 
tion of the simple and primitive type of knowledge and creed 
of early man. At such times no differentiation, or only a 
slight differentiation, could be drawn between his conception of 
the air he breathed and the soul which inhabited his body. At 
first, therefore, the soul was considered to be a gas or rarefied 
air. But after a time air was not rare enough to suit the 
philosophers. Soon they dethroned air, and set up fire : the soul 
was an internal fire, the source of bodily heat. When it de¬ 
parted the body became cold in death. 

Dualism as an Explanation .—For Anaxagoras neither air nor 
fire was subtle enough. He cast both aside, and postulated 
something entirely different, something with negative charac¬ 
teristics : the soul was immaterial. Thus dualism arose. 

These were necessary phases in the evolution of man. But 
dualism did not long remain unchallenged ; the rival theory of 
monism arose, and was put forward to reconcile the antagonism 
thus raised by the dualists between the material body and the 
immaterial soul. The monists merged the two apparently 
irreconcilable opposites in a higher unity of a still more trans¬ 
cendental kind : thus arose the monistic school, which cul¬ 
minated in the philosophy of Hegel (5) at the close of the 
eighteenth century. Both theories remain with us to-day. 

The Scientific Method. —Psychology must turn its back upon 

XLV. gie 



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SCIENTIFIC PSYCHOLOGY, 


[April, 


all such subtleties, which lead us only into perplexity. Suffice 
it for us that psychology observes, and studies, and treats of 
certain special phenomena, embracing a vast extent of the 
known. If we still use the words “soul ” and “mind,” we may 
do so in a definite and scientific sense. But such adaptation 
of terms to newer and clearer meaning should, however, be 
made only when there is need, and consistently with estab¬ 
lished knowledge. We shall have occasion to use the terms 
mind and psychical: these will require some explanation. 

Just as some phenomena which we observe in nature are 
called physical , others chemical , &c., so a certain class of 
phenomena—exhibited by living organisms—are called vital. 
A further section of living beings exhibit during life certain 
other phenomena yet more complex, which we designate mental 
or psychical. So far, and as descriptive titles, these terms are 
convenient and useful. But many writers in the past have 
gone beyond this. Not content with studying, observing, and 
describing the course, development, association, and sequence 
of various phenomena in the world, they have postulated subtle 
essences to explain (crudely, in fact) their occurrence : thus heat 
was due to a subtle essence or substance called “ caloric light 
was due to exceedingly fine “ corpuscles ” (the emission theory) 
which issued from luminous bodies, and constituted the real 
essence of light. Similarly the alchemists postulated “ spirits,” 
or “ essences,” to explain the different properties and behaviours 
of chemical substances. Similarly for the phenomena of life, 
growth, and movement which living beings exhibited: a 
subtle immaterial essence, the vital element or principle of life, 
was invoked to explain and account for these phenomena (6). 

In the following pages, however, the use of the words 
physical, chemical, vital, mental, psychical, &c., will not pos¬ 
tulate or connote the existence of any special undefined or 
undefinable essences as underlying phenomena. These terms 
will be used as merely descriptive. It is not necessary, then, 
to discard these terms, or to coin new ones. 

Mental or psychical phenomena are, to speak accurately, a 
certain special class of functions which living beings may 
exhibit, and which have their special seat in the nervous system. 
Or, to put it in other words—as we have stated it elsewhere (7),— 
“ mind is a brain function which is found in nearly all animals 
in varying degrees ; which in man arises from small beginnings 

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1899.] BY W. LLOYD ANDRIEZEN, M.D.LOND. 


26 l 


like any other function, then gradually develops and attains 
the acme of its complexity and activity in adult life, and finally 
fails and disappears with the decay of old age.” This is 
the basis and foundation on which the following studies will be 
built. 


Part II. 

The various steps in the evolution of consciousness in the 
organism (or in the race) are not so clearly defined and well 
marked as to be obvious to superficial examination. Often 
the progress is gradual and the time is prolonged ; moreover 
the rate is not uniform, but marked by apparent halts, “ crises,” 
and periods of slow and rapid evolution. At times, again, we 
see what are obviously defects, anomalies, and perversions, rise 
into being under the influence of noxious conditions of the 
environment, or of vicious ancestry, as in the morbid types of 
mind and conduct which belong to the various species of idiocies 
(aphrenia), imbecilities (oligophrenia), “degenerative insanities” 
(paraphrenia), and acquired insanities (prenopathies). 

Feeling as the Fundamental Element. —The first stages of 
development are now to be inquired into ; and here the bulk 
of the evidence is derived from biological investigation of the 
simplest living forms of plant and animal life, viz. unicellular 
organisms. In the lower forms of unicellular organisms Proto - 
soa , protophyta, spermatozoa, antherizooids, leucocytes) all 
microscopic research has so far failed to demonstrate the 
presence of definite or distinct nervous structures. In them 
one and the same cell body is able to react and respond in 
different ways to objects, to incidental stimuli, and to varying 
conditions of the environment generally. Special researches, 
directed with a view to elucidate these phenomena, have 
resulted in showing that apparently simple physical agencies 
( e.g. : contact), heat and light, and the presence of certain 
chemical substances (liquid or in solution) in the medium may 
determine definite and separate movements and responses of 
the living cell thereto ; and these phenomena have been for 
convenience of terminology grouped under such categories as 
chemiotaxis, thermotaxis , heliotropism , geotropism, &c. [The 
student who wishes to pursue this subject further should 
consult the chapters of Romanes' Mental Evolution in Animals , 

and the works of Binet (8) and Max Verwom (9)]. This power, 

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SCIENTIFIC PSYCHOLOGY, 


[April, 


therefore, of being (a) sensitive to different incidental stimuli, and 
(b) of responding thereto in definite and separate ways, is the 
property which living protoplasm, and the simplest protoplasmic 
organisms, animal or vegetable, possess: it constitutes the function 
of feeling\ the fundamental constituent and primordial factor in 
the constitution of consciousness. It is interesting now to observe 
how, as we ascend the scale of animal life and arrive at the next 
grade of the animal kingdom, the Metazoa (multicellular organ¬ 
isms), we find a specialised system of protoplasmic elements (cells) 
set aside for the same purposes indicated above, and thus for 
the first time a physiological division of labour is established, 
which is apparently in the best interests of the organism 
as a whole. Corresponding to this physiological differentiation 
of function there is a morphological differentiation of structure, 
which can be recognised by the microscope ; “ and among such 
morphologically differentiated tissues we find the first evidences 
of distinct nerve elements in the animal kingdom ” ( vide 
especially Romanes [Star-fish, Jellyfish, and Sea-urchins: a 
Research on Primitive Nervous Systems, 1880] and the brothers 
Hertwig [On the Sense-organs and Nervous Systems of the 
Medusce, 1880]). 

Segmentation of the Organism .—Thus early do the special 
elements and tissues appear which subserve all those activities in 
the life of the organism which we may specifically call neural 
and psychical, or neuro-psychical, as distinguished from the 
similarly differentiated digestive, reproductive, and other special¬ 
ised activities which are also associated with other specifically 
differentiated tissues. It further happens that in the course of 
evolution the Metazoa very soon exhibit a preponderance of 
growth, which assumes the form of segmentation. The body 
grows into an elongated structure of several segments, neuro¬ 
muscular, digestive, excretory, &c.; in short, each segment, while 
preserving an individual life of its own, yet joins and shares in 
that of its neighbours, thus constituting part of a more complex 
and complicated whole. Parallel with this increased size and 
complexity of the body generally there proceeds a correspond¬ 
ing aggregation and segmentation of the neuro-psychical 
elements into a central nervous axis, running through the 
whole length of the animal from cephalic to caudal extremity, 
and harmoniously uniting all. [The student has here only to 
recall to mind the nervous system of the common earthworm, 

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1899.] BY W. LLOYD ANDRIEZEN, M.D.LOND. 263 

leech, or caterpillar, to impress these facts more firmly in his 
mind (10).] 

The Encephalon .—The nerve elements, however, do not main¬ 
tain an equal degree of development in every part and segment; 
variations and inequalities of growth soon make their appear¬ 
ance ; a concentration or increase of growth takes place, espe¬ 
cially at the cephalic or anterior end of the body, constituting the 
encephalon or brain of all the higher animals (including all 
Vertebrates). 

The reasons for its development at the anterior or cephalic 
end of the body need not detain us here ; suffice it to say that 
this has been discussed in a separate communication of the 
present author, where other collateral biological and compara¬ 
tive facts of importance are also dealt with (vide Brain , Winter, 
1894, chapter “The Cerebral System,” pp. 567—9). Now 
the encephalon, as thus constituted, is a recipient organ for 
various kinds of sensorial stimuli, which arrive into it by various 
specific pathways, viz. ( a ) by the various special sense-organs ; 
( b ) by the kinaesthetic pathways from the various movement 
organs : the sensory end-organs being the “ spindle ” organs 
(muscle-spindles) of Kiihne ; the branching tendon-organs of 
Golgi ; the spiral fibres surrounding certain muscle-fibres ; 
and the Pacinian corpuscles of fascia, tendon, and muscular 
septa ; (< c ) by incoming tracts, whose starting-points are the 
glandular, digestive, secretory, and reproductive organs and 
tissues (viscera). It will thus be apparent that the encephalon 
is from the outset a great and complex sensorial recipient organ, 
in which are represented ( a ) the special senses, ( b ) the kinaes- 
thetic feelings, (c) the viscero-organic feelings. 

As we rise a little higher in the scale of craniate Vertebrates, 
/. e. to the level of the mammal, the encephalon is no longer 
merely an aggregate of such simple sense-and-feeling representa¬ 
tive centres. There are higher centres developed over and above 
these primary sensorial centres, viz. adnexa, associating centres, 
which are the seat of more complex psychical processes, which 
we thus come to name intellectual, emotional, &c.; functions 
of composite origin and complex nature, whose roots or starting- 
points are, however, to be sought for in one or other (or several) 
of the above-named specific sensorial, kinaesthetic, and coenaes- 
thetic centres. Our analysis thus leads to the conclusion that 
the seat, or organ of representation, of the specific sensations, 

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SCIENTIFIC PSYCHOLOGY, 


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and of the kinaesthetic and coenaesthetic feelings, is the ence¬ 
phalon ; the organ of feeling, sensation, and thought,—in short, 
of every form and quality of psychical life. 

It is possible, as we have shown in a previous paper ( Brain , 
Winter, 1894, pp. 567-8, and pp. 614-621), to recognise the 
main great groups of Vertebrates, including mammals, as charac¬ 
terised by broad and marked differences of nervous organisation. 
We shall here formulate the main facts established by our 
researches into the following table of classification, a tabular 
scheme first propounded by the author at the annual meeting 
of the Medico-Psychological Association in London, July, 1896, 
and which is here reproduced. 


Classification of Vertebrates (according to the Constitution of the 

Encephalon ). 


a. A crania. Amphioxus, Ascidians, and larval Cyclo- 

stomes. 

b. Craniata. Vertebrates with a skull developed around 

and over the encephalon. 

Group I. Archiencephala: with an anlage or rudimentary 
encephalon only. 

1. Cyclostomes. 

2. Elasmobranch fishes. 

3. Teleostean fishes. 

Group II. Palliencephala; with a pallium or cerebral 
mantle (cortex and white substance) developed out 
of and over the anlage. 

1. With predominant development of “ambiguous” 

layer of cells only ; this, together with the mole¬ 
cular layer, constituting a two-laminated cortex 
only, e.g. Amphibia. 

2. With predominant development of “ ambiguous ” 

and “ long pyramidal ” layers and systems only ; 
these, together with the molecular layer, consti¬ 
tuting a three-laminated cortex, e.g. (a) reptiles, 
( b ) birds. 

3. With feeble development of the “ambiguous” layer, 

marked development of the “long pyramidal” 
layer, and varying development of the “ poly- 


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1899.] BY W. LLOYD ANDRIEZEN, M.D.LOND. 


265 


morphic ” layer, these three, together with the 
molecular, constituting a four-laminated cortex, 
e.g> . mammals. 

Further Classification {tentative') of Mammals according to the 

Extent of Development of the Polymorphic layer , i. e.— 

a. With feeble development of the polymorphic layer, its 

average thickness being of cortex : e. g. Rodentia 
(rabbit, guinea-pig, rat). 

b. Medium development of the same layer, its average 

thickness equalling of cortex: e.g,, Carnivora (cat, dog). 

c. Considerable development of the polymorphic layer, its 

average thickness being -J of the total thickness of 
the cortex : e . g. Simioe (rhesus, macacus). 

d. Highest development of polymorphic system of nerve-cells, 

its total thickness being | to { the total thickness of 
the cortex ; also a predominant development of the 
white substance (corpus callosum, association fibres, 
and projection fibres): e.g . human brain. 

The above classification, based on a minute study and an 
extensive comparison of phylogenetic facts, gradually lead us 
to the conclusion that in the historical development and 
evolution of the vertebrate race, the winners in life’s race, 
especially the mammals, predominated, owing to (or in asso¬ 
ciation with) a corresponding pre-eminence in the growth and 
evolution of their brain ; a fact which acquires additional 
interest when we point out that, co-extensive with the start in 
the development of the pallium (cortex) in the amphibian 
(from the rudimentary archi-encephalon of the fish), there is the 
parallel phenomenon of the first differentiation and early evolu¬ 
tion of the pentadactyle limb (of the amphibian) from the rudi¬ 
mentary pterygium of the fish. Curiously interesting, and 
certainly striking as a fact, the parallel development of the 
brain pallium and the pentadactyle limb stand out conspicuously 
and in relief in the evolutionary history of the higher Verte¬ 
brates from the lower. The possibilities for a higher and more 
advanced development of the kinaesthetic functions therewith 
must be also kept steadily in view ; the growth of the brain 
upward in the vertebrate series from the fish and amphibian, 
through the reptile and bird, to the mammal and man, bringing 
constantly and continually with it a higher degree of com- 

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SCIENTIFIC PSYCHOLOGY, 


[April, 


plexity and greater extent of evolution, especially in its life 
of relation (kinaesthetic life) to the environment, and an increase 
of kinaesthetic representation in the cortex. The psychological 
significance and import of the above observations will have 
already dawned upon the student, and will prepare the way 
for further considerations and study of the neuro-psychical 
mechanism and its evolution. 

Part III. 

The child comes into the world with a brain which has but 
one third the weight of the adult brain. At the close of the 
first year of life the brain weight has doubled itself; it is now 
two thirds of that of the adult (11). 

Starting from these established facts, certain interesting 
details will now be described, reference being made to various 
mammalian brains as well as to the human brain. 

In the new-born and young of mammals (< e.g . kitten, rabbit, 
mouse, and other animals), while the individual nerve-cells 
(neurons) which compose the brain, and are aggregated into 
clusters and strata in the brain cortex, have already at birth 
reached thefulness andcompletion of their numerical growth (12), 
the individual nerve-cell in its entirety (neuron) has by no 
means reached the acme of its evolution. The progress of 
growth and development takes place mainly in two directions: 
(a) in the size of the cell body and its processes ; (b) in the 
extent, variety, and complexity of its connections. Certain 
changes of a structural and chemico-physical kind also take 
place within the cell protoplasm and nucleus too, and in their 
relative proportions to one another as growth and elaboration 
proceed. These phenomena are of the deepest import, for with 
careful and comparative observations we are able to see, to 
trace step by step, and in a measure, therefore, to comprehend 
and understand some of the deepest mysteries of psycho-phy¬ 
siological life as manifested in the nervous mechanisms and 
organisations which subserve it at these early stages of life. 
The evolutionary processes may for convenience be examined 
under the two aspects of quantitative and qualitative evolution. 

Quantitative Evolution: Growth in Size of the Neuron or 
Brain Cell .—In the kitten at birth, and for some little period 
on its way to adult life, growth in size of v the cell body takes 

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place in the brain cells. But this soon ceases ; and in the 
young cat of a few months old, and in the adult one of two or 
three years old, the cell bodies do not differ in size. The pre¬ 
sent author, from observations on the brains of young kittens 
(about six or seven months old) compared with full-grown cats 
(of rather over a year old), could further find no appreciable 
difference in the size of the nerve-cell bodies in the following 
regions of the brain cortex ; viz. ( a ) the anterior limit of the 
sigmoid gyrus, and ( b ) the uppermost arcuate (marginal) convo¬ 
lution. 

Having compared also the cell bodies from the ascending 
frontal convolution of a child two and a half years old with a 
number of brains from adults of various ages (twenty-five to fifty), 
the present author failed to find any notable difference in the size 
of the brain-cell bodies for corresponding regions of the brain. 

On the other hand, it is a notable fact, observed by Vignal 
(and confirmed by the present writer), that in a foetus of five 
months the cell bodies of the cortex are distinctly smaller (13) and 
more closely packed together in the cortex,—indeed, so closely 
that in many specimens the nuclei of the cells seemed almost in 
contact with each other. But towards the close of foetal life, 
and at about full term, what would seem to occur in the human 
foetus and new-born, and in foetal and new-born animals, is as 
follows : 

The cell bodies grow in size, till at birth they have very 
nearly reached the limit of size (plumpness and rotundity) ; 
that limit is, however, reached at slightly varying periods, but 
in any case and generally while the animal is still very young. 

But meanwhile the brain as a whole continues to grow 
rapidly, steadily, and conspicuously in bulk, whence it happens 
—as we have stated at the beginning of this section—that the 
brain weight (in the human being) doubles itself in the first 
year of life. In the human brain, as in the brains of mammals, 
it is seen that towards the close of foetal life, and in the early 
months of extra-uterine life, the cell bodies of the cortex seem 
to get further apart from one another—much more so than 
their very slight increase in size would be adequate to account 
for ; and this phenomenon was explained by some of the earlier 
authors as due to an increase of blood-vessels, of neuroglia, or 
of ground substance (Boll). 

Our own researches, following in the footsteps of Golgi, and 

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SCIENTIFIC PSYCHOLOGY, 


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based on the study of a series of kitten brains of various ages, 
from the foetus about a week before full term to the young 
kitten about a month old, have shown us, however, that the 
cause of the apparent (and indeed real) separation of the cell 
bodies is not due to the growth of non-nervous structures 
pushing the nerve-cell bodies further apart, but really to the 
next factor, viz. the increase in the growth in size, extent, and 
complexity of the various cell processes (protoplasmic pro¬ 
cesses, nerve-fibres, collaterals, and terminals) issuing from the 
cell body, the full and precise recognition of which in all their 
extent of growth and complexity of branching has been only 
possible since the use of Golgi’s method. The evolution of the 
nerve-cell in these respects can be more readily and properly 
included under the category of qualitative evolution. 

Qualitative Evolution .—On the anatomico-physiological side 
this comprises the growth in the extent and complexity of connec¬ 
tions of the protoplasmic and nervous processes of the brain cell. 
This is the real and fundamental fact as shown by the Golgi 
method. 

The growth which takes place during the close (last month) 
of intra-uterine life, and during the period of infancy, is, as far 
as the cortical nerve elements are concerned, not a numerical 
increase of elements ; it is to a slight extent a growth in size of 
the cell body : but in the main and most notable extent it is a 
growth of the processes in the way mentioned above, viz. a 
qualitative growth. The nerve-cell bodies, which in intra¬ 
uterine life seemed close packed and touching one another, now 
get separated from one another, being pushed apart by the 
extraordinary growth of protoplasmic processes emanating and 
growing out from the cell body, either as apical or basilar pro¬ 
cesses in definite directions, or (apparently) more irregularly in 
all directions ; and simultaneously with this a parallel growth 
of medullated nerve-fibres, collateral and terminal fibrils, also 
takes place from already existing axis-cylinders which pervade 
the cortex also. The cortical nerve-cell bodies remain numeri¬ 
cally the same; no karyokinetic division and increase of 
number can be observed. But the increased growth of proto¬ 
plasmic and nervous processes pushes them further apart, and 
hence the nerve-cell bodies seem apparently to get more sparse 
in the growing brain. 

In a previous communication the author has given illustra- 

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269 


tions showing the nature of some of these changes, for further 
information regarding which the original paper must be con¬ 
sulted {vide Brain , Winter, 1894, pp. 640-42). 

It must be added that all parts of the cortex (/. e . various 
“ centres ”) do not develop equally or simultaneously ; there are 
local or regional variations (14). Similarly in any one area or 
centre the various nerve elements which constitute the several 
cortical layers do not grow and develop uniformly or at the 
same time ; some cells have advanced considerably in develop¬ 
ment (< e.g . the large pyramidal cells of the Rolandic or sig¬ 
moid area), while other smaller pyramidal cells are in a more 
backward stage ; while again the polymorphic elements are at 
this stage almost the least developed, and therefore youngest of 
the cortical elements. There is not only a heterogeneity of 
structure and of function, but a heterogeneity in the times and 
rates of development of the cortical elements of the brain. 
Growth and elaboration are going on in different parts (tracts 
and centres) at different times and at different rates, and so as 
to subserve the various functions which, gradually and selectively 
evolved and perfected in the long ancestral past of the species, 
now appear in orderly co-existence and sequence in the actual 
early life of the organism, with a regularity and stability bom 
of the accumulated hereditary conditions in the aeons of the past. 

Physiological Elaboration .—By this growth and elaboration 
of the cortical neurons certain possibilities are realised. The 
cortical mechanisms for the various sensorial processes, as well 
as for various movements, are rendered capable of being trained 
and perfected. For with the growth of the protoplasmic expan¬ 
sions (dendrons), and the contact granules situated thereon 
(epidendritic granules), these latter come into functional associa¬ 
tion with a greater and greater number of fibrils which pervade 
the strata at various depths of the cortex, the molecular layer 
first and most abundantly, and more diffusely the various other 
cortical strata also. 


They (/. e. the nerve-cells whence these processes arise) there¬ 
fore can receive and react to a larger number of incoming 
excitations reaching them from (a) cells of the same area, or 
from ( b ) associated (sensorial or kinaesthetic) areas of the same 
or opposite side, or (c) from the areas of the cortex not so 
specifically defined, or ( d) from the upward sensory projection 


fibres (fillet system, optic radiations). 

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SCIENTIFIC PSYCHOLOGY, 


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And, with the increased growth in number and extent of col¬ 
laterals, the superficial pyramidal cell, like the ambiguous cell, 
is able to transmit currents (excitation of its own) to the 
neighbouring and deeper lying pyramidal cells, whose apical or 
basilar expansions these horizontally running collaterals touch. 
This serves not only to render the whole body of nervous 
excitations from the cells discharged down any one tract (e.g. 
pyramidal tract) consolidated as it were en masse , but by such 
means of neuro-protoplasmic contact, whereby the upper cells 
can influence the lower in series, capacities for nerve action are 
furnished which by the special growth of this or that proto¬ 
plasmic branch, and this or that collateral and terminal related 
thereto, can grow into definite and well-integrated nervous 
mechanisms for subserving various movements which we know 
various cortical areas are possessed of. 

Education .—In intra-uterine life the environment is sensibly 
constant and uniform, the variations therein being slight in 
character, slow in rate, and (in health) of steady persistency; 
the sentient life of the foetus is at its lowest ebb (somnolescent 
and vegetative stage). 

After birth variety begins in life ; and with variety in the 
environment there begins, or should begin, the first marked 
variations and disturbances in its sensorial and kinaesthetic and 
organic life. The training and education of the nervous system 
now begins. At first there is much confusion and turmoil—a 
condition of necessity imposed on the neurons, which are them¬ 
selves rapidly growing, and are at the same time being sub¬ 
jected to varied, intense, and novel stimuli from the environ¬ 
ment. There is a weakness and unsteadiness as well as a 
violence in its reactions, together with much that is at first 
aimless and superfluous in the way of muscular action ; its early 
weak and unsteady movements of dyskinaesis grow gradually 
and slowly—by a tedious process of repetition and education 
of certain movements, and the non-repetition of others—into 
the later, stronger, and steadier movements of eukinaesis which 
appear as growth goes on. Yet here again we find that not all 
movements and acts develop evenly or equally ; there are varia¬ 
tions of a very definite sort. The new-born child can perform 
some movements well ; the nervous organisation for these has 
been almost perfected in the bulbo-spinal centres already, and 
requires but the presence of adequate stimuli to call them forth 

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1899.] BY W. LLOYD ANDRIEZEN, M.D.LOND. 


271 


almost in perfection. Among such may be mentioned the 
movements or acts of ( a ) breathing, ( 6 ) crying immediately 
after parturition, ( c ) sucking, and ( d ) simple grasping with the 
hands and fingers an object placed within the hand. To 
these may be added the special respiratory reflex movements of 
(e) sneezing and (/) coughing ; all of which, when suitably 
evoked, will be seen to be well performed (15). A second cate¬ 
gory comprises (g) reflex movements of the limbs, generally 
from contact with objects (bedding and clothing, person of the 
mother, nurse, &c.), as well as with cold air. These are mostly 
quick, sometimes sudden, rapid, and random movements, of 
small extent, and of aimless purpose apparently ; to this group 
should also be added (A) aimless or purposeless sounds uttered 
by the voice also, and (/) the occasional movements of starting 
observed in the infant. Crying at the feeling of hunger ; (A) 
does not perhaps come under this category, though could we 
trace more clearly than we can the nexus of cause and effect in 
all these movements we might possibly find the number of so- 
called purposeless movements restricted to quite a few only. 

Instinctive acts begin to appear later in the child, and inter¬ 
mixed with these at a still later date definitely imitative acts 
and movements appear. Together with these instinctive and 
imitative capacities there develop the corresponding emotions 
of child-life. With the first impulses to imitation those to 
significant vocalisation are born. Emulation rapidly ensues, 
pugnacity follows in its train. Fear of definite objects (partly 
instinctive, but partly also acquired in association with painful 
or disagreeable experiences) is also developed early, though at 
variable times in the human young. Play, curiosity, and 
acquisitiveness (and even greed), all begin also very early, and 
manifest themselves within the first two years of life. Other 
instincts develop later. The progress of cerebral growth and 
organisation rapidly goes on meanwhile (as a rough indication 
of this, the curve of brain-weight in infancy may be studied by 
the student, together with the chapters on quantitative and 
qualitative evolution in our previous work in Brain , Winter, 
1894. The protoplasmic processes and epidendritic granules 
of the brain-cells, their growth in size, extent, and complexity 
of connections, the internal elaboration in cell body and nucleus, 
and the correlative growth of nerve terminals and collaterals in 
the brain, are thus of the profoundest significance ; the growth 

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SCIENTIFIC PSYCHOLOGY, 


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of each terminal dendron, the formation of each epidendritic 
granule, and the coming into contact of these with nerve-fibrils 
(terminals and collaterals), constituting the milestones—or per¬ 
haps the inches and footsteps—which mark the slow advance in 
the countless constituents of cerebral (mental) organisation. 

[The student who wishes to have a detailed knowledge of the 
various tracts in the brain, their connections with the various 
centres, &c., should consult the works of Arnold, Meynert, Sachs, 
Bianchi, and the text-books of Dejerine(i6) and Kolliker (17).] 

The progress of our investigation is now ripe for our taking 
up the next great theme, the law of psychogenesis. 

Law of Psychogenesis ,—The known facts concerning the 
mode of development of the brain—as an organ of mind— 
furnish material wherewith to construct one side of the scheme 
of educational training which the growing brain of the child 
is capable of receiving. Education is the practical appli¬ 
cation of such knowledge. And from this standpoint educa¬ 
tion is not merely a social convention, but a real means for 
attaining real ends by the medium of an organisation—the 
cerebral organisation—which the child is endowed with at 
birth, which is plastic and improvable, capable of high develop¬ 
ment and elaboration, and peculiarly impressionable to the 
environment during all the early period of its evolution from 
infancy to adolescence. 

From the modern and scientific standpoint, therefore, educa¬ 
tion means such an unfolding and developing of the general 
cerebral and special mental functions as shall put the indi¬ 
vidual into the widest and most effective relations with the 
environment—physical and material, social, moral, ethical, and 
religious ; so that all those functions and capacities shall be 
developed to the best and widest extent, which shall make for 
the conquest and governing of the world of nature on the one 
hand, and for the understanding and fulfilling the duties and 
responsibilities of family, social, and national life on the other. 

In the child the whole progress of education and acquisition 
of knowledge is a long, a tedious, and an effortive toiling, 
accompanied by varied painful and pleasurable emotions, and 
by a more or less continuous psychical turmoil. On the 
executive side there is the slow and tedious development of 
the kinaesthetic mechanism, associated with the correlated 
growth of the auxiliary co-operating visual centres (18); on the 

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273 


side of speech utterance there is a similar gradual effortive and 
tedious evolution of the glosso-kina:sthetic and the auxiliary 
auditory mechanisms also, in all cases from dyskinaesis to 
eukinaesis. And while these numerous evolutions are taking place 
in the Rolandic area (kinaesthetic sphere), whereby the cortical 
mechanisms which subserve the higher executive phenomena 
(which we term acts, speech, conduct) are perfected, there is 
taking place on the sensorial side a somewhat parallel develop¬ 
ment, whereby distinctness and vividity of sensations, their 
sharp integration and differentiation from one another, and the 
capacities for their ^^/-spontaneous revival (recollection) in 
the brain are rendered possible. 

Between these two great spheres, the sensorial on the one 
side and the kinaesthetic on the other, lies what, for want of a 
better title, we may call a transition region, varying in extent, but 
of the existence of which we are sure on anatomico-physio- 
logical, psychological, and pathological grounds (19). 

In the child the march of evolution, as all observation 
shows, is in general terms from dyskinaesis to eukinaesis for 
movements, speech, and acts generally. Similarly, and pari 
passu , the child's capacities for sense-perception also get improved, 
better defined, and intensified. It passes through the lower 
grade of imperception to the higher grade of apperception. In 
the earlier functional stages the various sensorial and kinaes- 
thetic currents (messages) arriving in the brain excite neurons 
which are themselves rapidly growing and changing, and which 
from that fact alone are the seat of a continuous psychical 
turmoil. 

The psychological state which accompanies these conditions is 
one in which, with such change, rapid growth, conflict, variety, and 
turmoil, the empirical ego is not yet consolidated, and the unity of 
psychical life is not yet felt and realised ; there is as yet no formed 
and unified ego, it is in course of formation—inchoate, chaotic. 
On the brain thus formed and forming the external logic of 
things has a potent and, indeed, a remarkable influence. 
Various objects, individually and in sequence, and in simul¬ 
taneity, in various ways and under various associated condi¬ 
tions, tend to be presented again and again to the child. The 
individual sensations get defined and integrated. A series of 
separate and varied sensorial images are thus impressed on 
the cortex. Similarly the process goes on in the various 

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SCIENTIFIC PSYCHOLOGY, 


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portions of the kinsesthetic area. Further, the occurrence of 
two or more objects in the environment affecting the child has 
to be considered. At first resulting in confusion, this is soon 
replaced by combination or association of the corresponding 
cortical images. The apposition (concurrence) of two events 
without, i. e. in the external environment, soon calls up in the 
mind a corresponding combination (or association) of two 
sense perceptions within, /. e. in the brain. Similarly the 
sequence of phenomena without, acting on the sensorial sphere, 
calls up a sequence of perceptions within. There are the rudi¬ 
ments for the association of ideas ; the occurrences and im¬ 
pressions of nature are the pabulum for the growing brain of 
the child. Observations on young children will reveal daily 
numerous instances in which their mental growth is seen to 
take place along the lines thus indicated (in all the above 
observations it is of course premised that the child is healthy and 
properly nourished). Some further considerations will now be 
entered into on the law of psychogenesis in connection with 
the subject of languages. 

Language ; its Co-operation in Brain Development .—“ The 
teaching and learning of language is, for the child, not a neces¬ 
sity, but a convenience ; it allows it to represent things by a 
common denominator.” This is the whole value of the thing, the 
crux on which its merits rest, as we have stated in a previous 
publication {Brain, Winter, 1894, p. 646). And the child is 
continuously doing this. An analysis of this part of our study 
reveals in detail how language is useful and valuable. It is 
useful in proportion to—( a ) its symbolising (or representative) 
power ; (< b ) its comprehensiveness ; ( c ) the economy of labour 
and time in expressing and communicating ideas ; ( d) its ability 
to lead to higher and more complex and also more abstract 
symbols, conceptions, expressions, and formulae of the highest 
order or value, as in the sciences, arts, and literature. Its 
immense value as an instrument for the reinforcement of psy¬ 
chical activities (which, however, can take place in its absence) 
co-operates greatly in brain development ; it is capable of re¬ 
presenting the most varied and different things in common and 
convenient terms, and it is of the highest formal value in the 
exercises and repetition of psychical processes which underlie 
mental evolution. 

It thus comes about that by the help of words and language 

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275 


we are able to climb into higher regions of abstraction, to 
experience more complex emotions and feelings, to command 
more complex processes of thought. 

Similarly for numbers and mathematics ; man begins by 
counting things, giving to each unit a name. So the names for 
the first few (say ten) units arise. All this is done in the con¬ 
crete, and by the use of little stones, sticks, or the fingers and 
toes. He then learns to count in the absence of things , now 
using the numbers as symbols, 1. e . as words uttered or written. 
With these abstract signs arithmetic begins. From this he 
passes to higher and more complex representations ; to the 
signs, symbols, and operations of algebra, where the terms and 
signs are not only abstract, but general—representative in a 
higher degree ; he calculates not merely numbers, but numeri¬ 
cal relations. From this again he passes higher into the 
calculus of functions, their variations (fluxions), and to relations 
of the highest and most complex sort. He thus furnishes 
the economic process and time-saving formulae for mechanics 
and machinery, engineering, optics, electricity, chemistry, navi¬ 
gation. 

Further, much of its knowledge of nature and its individual 
surroundings are by the child acquired (in early childhood) in 
a rather passive way. Some of the foregoing observations 
will have already served to point out this feature, especially 
as regards the development of its concrete concepts of things. 
Psychological observers are generally agreed on this point, 
which is well stated by Sully : “ The more concrete concepts or 
generic images are formed to a large extent by a passive pro¬ 
cess of assimilation. The likeness among dogs, for example, is 
so great and striking that when a child, already familiar with 
one of these animals, sees a second, he recognises it as identical 
with the first in certain obvious respects. The representation 
of the first combines with the representation of the second, 
bringing into distinct relief the common dog features, more 
particularly the canine form. In this way the images of 
different dogs come to overlap, so to speak, giving rise to a 
typical image of “ dog.” Here there is very little of active 
direction of mind from one thing to another in order to dis¬ 
cover where the resemblance lies ; the result forces itself upon 
the mind. When, however, the result is less striking, as in the 


case of more abstract concepts, a distinct operation of active 
XLV. 



276 SCIENTIFIC PSYCHOLOGY, [April, 

comparison is involved ” (Sully’s Outlines of Psychology, p. 342). 
In the child’s mind both kinds of processes are going on, 
and, with the aid of language, further evolution in both 
directions is rendered possible. Thus, to quote an example 
given by ourselves previously, the child learns to call its nurse 
“ Bi,” and its term for to hide is “ tik.” The nurse hides behind 
the curtain, and the child learns to express it by the term “ Bi- 
tik.” But one day it looks out of a window and sees the sun 
getting covered over by a dark cloud, and the child now, on 
this novel occasion, cries out “ Bi-tik ” several times, pointing 
its finger to the cloud. Already the child had learnt to utter 
the two words together in the nursery for a special purpose, 
and now under other skies the same expression reappears—is 
re-uttered under the novel circumstances just noted. The 
somewhat crude similarity in the external sequence of events— 
a bright and conspicuous object, a dark curtain, and the one 
disappearing behind the other—combine to furnish the new 
material for the building up of a new compound idea ; new in 
one way, and yet not altogether new, but having affinities 
(resemblances) to an item in the child’s previous experience. 
The present author thinks that in this case the correct 
mode of regarding the law of psychogenesis is not to assume 
that the child in a deliberative and volitional and effortive way 
utters this proposition, but rather that this is effected for the 
child by the external logic of events. The formation of such 
rudimentary propositions first, and their extension then to 
things new and yet similar to and comparable with things 
familiar,—these two processes are the basis of psychological 
development in the child. Children see resemblances early, 
and they are exceedingly and crudely anthropomorphic. The 
young child seeing for the first time dew on the grass, and 
calling out to its father, “ Father, the grass weeps,” though 
uttering what the adult might, in his superior knowledge, call 
a quaint, and even poetic conceit, is really jumping to a crude 
anthropomorphic conclusion, from its superficiality of knowledge 
and insufficiency of experience. All these characteristics are 
known attributes of the child’s mind, and they have accordingly 
been taken advantage of by some keen observers of child- 
nature, to found thereon a system of education and practical 
training, with which the name of Froebel is more particularly 
associated. This method of infant training, to which the name 

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1899.] BY W. LLOYD ANDRIEZEN, M.D.LOND. 277 

of “ kindergarten ” has been given, is now extensively adopted. 
Froebel devised a series of exercises for young children, beginning 
at the age of three or four. Realising that the first thing the 
child wanted to do was to see, grasp, handle, and move about 
things, and to exercise his senses and limbs generally, and par¬ 
ticularly in play and sport, he sought to arrange a set of simple 
and appropriate exercises and employments with a conscious 
educational purpose, and in careful obedience to the suggestions 
of nature. We can only enumerate them : (a) wooden bricks, 
simple or multicoloured, for arranging and building up models and 
designs resembling objects ; (b) coloured papers for folding into 
various patterns ; (< c ) plaiting of straw or slips of paper into 
patterns ; (d) pricking diagrams and pictures on paper, followed 
by sewing the same with coloured threads ; (< e ) tracing of lines 
of gradually increasing length, number, and complexity, to 
develop new and pleasing geometrical patterns ; (/) organised 
games, dances, and physical movements of a rhythmical kind 
to simple music ; (g) acting and little dramatic performances 
resembling real life and work, as in the garden, the kitchen, 
farm, street, &c. 

All these were but the outcome of a simple yet intelligent 
appreciation of and sympathy with the child’s mind. Further 
developments have been initiated by various teachers since, and 
no more interesting account of a few of the new departures can 
be found than in the excellent and suggestive little work of Dr. 
Mary Jacobi {Physiological Notes on Primary Education and 
the Study of Language, New York, 1889). 

Another neurological fact of importance in psychogenesis 
must be also specially referred to, viz. the rhythmic and quasi - 
spontaneous activity of the brain. The brain is not merely the 
plastic and educable mechanism which we have hitherto found it; 
it has its broad rhythmic periods of enhanced and diminished 
functional activity. Propositions uttered by the brain as the 
result of an apposition of mental images tend to be repeated— 
either with conscious pleasure, with effort, or even seemingly 
unconcernedly—by the child over and over again. Like a 
haunting tune or strain of melody in the cultured ear, so 
common objects, daily impressions, and ideas related thereto 
run their nervous circuits over and over again in the child’s 
mind. This happens, as observations on children show, when 
the child is in a different environment, and occupied with other 

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SCIENTIFIC PSYCHOLOGY, 


[April, 


things than these recurrent images and thoughts. In the 
absence of presentative stimuli there is a ^{^/-spontaneous 
revival of the juxtaposed ideas in the mind which occurred in 
the past, and their repetition over and over again—a re-visual- 
ising of things seen before, a re-hearing of things heard, and 
re-vivifying of things previously felt and experienced. And 
so it comes about that experiences and incidents apparently 
trivial to the adult eye contribute to form the mental structure, 
and shape to some extent the temper and disposition of the 
child ; and the accumulated mass thus formed and forming 
serves to modify nearly all subsequent actions. Association and 
habit go hand-in-hand. 

Further Mental Evolution : the Ego .—The vividness of the 
child’s memory for sensuous impressions, its love of bright- 
coloured and showy things—toys, books, dresses,—its fondness 
for gorgeous and fairy tales in which sensuous elements prepon¬ 
derate, the vividness of its dreams and of its terrors (e.g. night 
terrors), all conspire to show how the sensorial sphere is growing 
and developing in early childhood, and how associations of ideas, 
vivid mental images of objects and occurrences, and the capa¬ 
city for their rhythmic, frequent, and spontaneous revivals in 
the mind are actually realised ; how simple sensations combine 
and cohere into complex ones ; how simple ideas of the con¬ 
crete combine and overlap into generic ideas ; and how, when 
simple ideas from sufficient repetition get sufficiently organised, 
they get spontaneously or indirectly, and by way of circuitous 
mental routes, recalled at times, and without any obvious, pre¬ 
sentative, external stimulus. In other words, there come about 
times and stages of development for the various centres and 
mechanisms of the brain, when the external logic of events 
is no longer a sine quA non needed to revivify them. They 
arise spontaneously as reminiscences, or in association with 
trains of thoughts and feelings which, indirectly and circuitously, 
recall them (recollections, memories). The feelings of spon¬ 
taneity which accompany these thoughts of the child gradually 
cohere into a complex mass, the empirical (sensorial-kinaes- 
thetic) ego as the source and centre of such feelings. Other 
and further factors also enter into and form part of this highly 
complex mass. By so much as objects in the external world 
oppose the ego, constitute obstacles to its spontaneous and 
overflowing activities, by every obstacle overcome, every pain 

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1 899.] BY W. LLOYD ANDRIEZEN, M.D.LOND. 279 

felt, so there is a clearer severance established between the ego 
and all these others, its antagonists, the non-ego. Further, the 
organic feelings arising from growth, metabolism, the action of 
the viscera, &c., during healthy life (ccenaesthesia), all contribute 
their constant and indeed voluminous quota towards the 
groundwork and foundation of the ego. It will thus be seen 
how, even expressed in general terms, the ego is a complex of 
the most numerous and heterogeneous sensations, feelings, 
memories, tendencies, habits, gradually evolved in different ways 
and directions, and gradually consolidated and united into a most 
complicated whole. It will be seen that the ego is thus built 
up gradually and empirically, and is gradually integrated and 
demarcated, gradually recognised as distinct from external 
objects. This is therefore the fourth stage ; the next gradual 
evolution from the earlier sensuous and rudimentary rationalis¬ 
ing stage of the child, viz. the stage of self-particularising and 
integration of the ego. 

We shall now find it convenient to briefly recapitulate these 
four stages in the development of the human brain (mind), 
broadly speaking: 

a. The vegetative, somnolescent stage (of intra-uterine life). 

b. The immanently sensuous and non-rational stage (first 

months of life). 

c. The primitive rational stage (latter part of the first year, 

and second year of life). 

d. Stage of self-particularising and integration of the ego 

(from the third year onwards). 

These various stages are never sharply defined ; they gradu¬ 
ally blend in parts, and overlap considerably in others. This 
is naturally to be expected ; the ego is an infinite complex of 
sentient units, and all parts do not develop evenly or equally. 

We shall now trace the processes of psychogenesis and the 
evolution of personality a little further. 

With the increased extent and multiformity of the environ¬ 
ment with which the child comes in contact, with every increase 
in the amount of obstruction and antagonism encountered and 
overcome, the empirical ego grows in clearness and integration, 
and in its feeling and consciousness of separateness from all 
else—the non-ego. The rapidly growing fore-brain gradually 
begins to assert itself, gradually but decidedly taking its part as 
the predominant partner of psychical life; each new activity, 

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SCIENTIFIC PSYCHOLOGY, 


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each struggle, each painful (and to a less extent pleasurable) 
feeling but serves to sharpen the feeling of contrast between 
ego and non-ego, and to integrate the ego. Thus true self- 
consciousness arises. Habits are gradually formed. Inherited 
instincts and propensities now seek for more determinate ex¬ 
pression, as the mechanisms of expression, speech, and action 
(Rolandic or kinaesthetic centres) are developing and become 
more and more efficient servants of the organisms. Between 
these on the one hand, and the wider and newer conditions 
imposed by nature and the environment on the other, there is 
a continual stress and conflict. New and added experiences 
and restraints come into play—home life, school life, the rule 
of parents and guardians, moral and social precepts and limita¬ 
tions. All of these act on the ego in determining its final 
shaping and disposition ; all contribute towards the perfect 
formation or deformation of the ego, surrounding, controlling, 
coercing, and limiting or encouraging its growth, expansion, 
and tendencies in this or that direction ; compelling recognition 
of and obedience in great measure to nature and the com¬ 
munity. He learns to conquer nature (intellectual progress), 
and to perceive and realise relationships and the duties arising 
from relationship (moral progress). And thus the tedious battle 
and struggle, which is the necessary condition of the highest 
evolution, goes on during later childhood. At the close of this 
period another and different series of phenomena are entered 
upon ; a rearrangement, almost a crisis, occurs in the organic and 
psychical life. This is the period of puberty and adolescence. 

Puberty and Adolescence .—Before proceeding further, how¬ 
ever, it will be well to tabulate in a measure the general 
characteristics of childhood, in order that we may be able to 
comprehend and realise more clearly the following remarks, 
which deal with the conditions and traits of puberty and 
adolescence. The general characteristics of healthy childhood 
are as follows : 


1. Domination of the immediate and the sensuous. 

2. Deficiency of reflection, and of regard for the future 

(prudence). 

3. Emotional instability, impulsiveness. 

4. Credulity, suggestibility. 

5. Aggressiveness, grasping for power and the tyrannical use 


of it, greed. 


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!899*] BY w - LLOYD ANDRIEZEN, M.D.LOND. 


28l 


6. Absence of altruism, bigotry. 

7. Exuberance of boisterous and sportive instincts, overflow 

of animal spirits. 

The moral or ethical nature, which really means the 
holding of the emotions, appetites, and passions in check, 
under the dominion of the higher psychical centres (judgment, 
and exercise of will), is the last and slowest to be developed 
in the child. And assuming that ( a ) no intrinsic antenatal 
vice, blemish, or disease is present, and ( b ) that the brain has 
not been invalided by disease or accident in childhood, the 
germs are there for the making of a morally as well as intel¬ 
lectually healthy and well-proportioned nature. Meynert had, 
as long ago as forty years, stated (in his Psyckiatrie, 1859) 
that the fore-brain is an inhibitory apparatus against the lower 
and more instinctive natural impulses ; and the more recent ex¬ 
periments of Goltz and Luciani on decerebrated dogs have largely 
borne towards the same conclusion. In the human brain, 
however, the fore-brain (cerebral hemispheres), from its pre¬ 
ponderating growth, becomes more than that. For the higher 
its development, the greater is the tendency to subordinate the 
particular to the general. Even in the insect kingdom this has 
been observed ; a high social growth and order takes place, as 
in the bee and ant communities. The same is the case in the 
higher (adolescent and post-adolescent) development of man. 
In the child, however, a being largely wrapped up in its 
instincts of self-preservation, the “ primary ego ” (of Meynert) 
is predominant, and the child is an egoistic being, greedy and 
grasping, dominated by the immediate and the present, a 
parasite, with all its instincts converging towards the animal 
self. As development goes on this stage is passed, the fore¬ 
brain, with its increased relational life and all that that implies, 
acts as a check to the purely vegetative functions and appetites, 
and a “ secondary ego ” is developed which takes precedence of 
the primary one ; morality and conscience grow and assume 
priority. This is the general law or order of society, which we 
call civilisation and social order. It will be clear, then, that if the 
fore-brain (which is thus largely an inhibitory apparatus in the 
sense of Meynert) become enfeebled in growth, or diseased or 
disordered, predominance of the natural instincts, passions, and 
propensities would occur (paraphrenia); and when its functions 
are almost wholly arrested in the course of evolution (aphrenia, 

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SCIENTIFIC PSYCHOLOGY. 


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oligophrenia), or greatly lost and dissolved (dementia, lipo- 
phrenia), the individual is in the position of an idiot or 
imbecile, a criminal, anarchist, or paranoiac opposed to the 
ethical order of society, or a dement in the last stage of mental 
dissolution, and reduced to a somnolescent vegetative life, a gross 
caricature and far-off resemblance of the foetal life. These 
possibilities need to be borne in mind in view of a classification 
of those diseases of the brain which involve its mental functions 


— i. e. the insanities—being contemplated at the conclusion of 
this paper. 

The onset of puberty and the progress of adolescence bring 
with them certain important and profound organic (bodily) and 
cerebral (mental) changes in the organism. A new world is 
gradually opened to it. Sexual development and differentiation 
take place rapidly; the sexual organs and their accessories 
(ovaries, testes, external genitals, and in the female the 
mammae) develop rapidly; the heart and vascular system 
grow pari passu , and a fresh feeling and consciousness of 
power, a fresh body of emotions, all arise. The pelvis in the 
female, the larynx in both sexes, enlarges ; feelings of pleasure 
vaguely felt in the presence of the opposite sex, a love of 
idealism and amorous romance, a desire for self-sacrifice, and 
vague emotions of an altruistic and even mystico-religious kind 
are developed. These, again, may in some be erratically or 
abnormally developed, giving rise to the profounder forms of 
hysteria (hysteria major), religiosity, and mysticism of the para¬ 
noiac type, to sexual intemperance and perversions, and other 
mental abnormalities. In others, again, the changes and develop¬ 
ments of puberty and adolescence may result in arrogance, 
excessive conceit, and a violent boisterousness and wild, riotous 
behaviour, coming close, it may be even to the confines of adoles¬ 
cent insanity. And in others again the adolescent may emerge 
from this critical period with his feelings and sympathies 
broadened, softened, and deepened, in which the purely selfish 
and self-assertive stage is largely built over with the higher 
state, self-sacrifice and altruism, the two necessary requisites 
for the higher development of human character. (Further 
researches on this stage of development will be dealt with in 
a future communication.) Here our exposition of the law of 
psychogenesis must stop, and we must now briefly deal with 


its opposite, the law of pathogenesis, under which the cerebral 

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1899.] BY W. LLOYD ANDRIEZEN, M.D.LOND. 


283 


organisation and consequent evolution of personality, and the 
psychical life generally, is arrested , enfeebled, deformed , deranged , 
or destroyed , and the results accruing therefrom briefly classified 
in a natural way (classification). 

Part IV. 

Pathogenesis and Classification .—It will be evident to the 
reader who has closely followed the subject thus far that abnor¬ 
malities (morbid changes and alterations) may occur, and do 
occur, at all stages in the evolution of the brain and its func¬ 
tions, from the foetal (vegetative, somnolescent) to the sexually 
mature (adolescent) stage ; and it will be further evident that 
the corresponding evolutions of personality, of bodily conforma¬ 
tion and appearance, and of conduct and capacity for intellectual, 
social, and ethical life, will vary correspondingly in the subjects. 

This is our basis for the classification of Insanity . Dividing 
the whole mass of such subjects or patients into two great 
classes or series, at one end of which hereditary, foetal, and 
intrinsic vice of organisation so preponderates as to result in 
profound arrests and defects of cerebral (psychical) evolution, 
we find that at this end of the series come the more profound 
degrees of idiocy (aphrenia), viz. the helpless, wet and dirty, vege¬ 
tative somnolescent idiots. At the other end of the scale come 
those morbid conditions which occur in or affect brains of nearly 
full cerebro-psychical development. These cases would not, and 
as a rule do not, present any striking anomalies of brain or bodily 
development, and may for convenience of designation be 
included under the term phrenopathies , acquired morbid 
conditions of the nearly full-developed brain, e.g. the simple 
vesaniae (mania, melancholia, stupor), the toxic encephalo¬ 
pathies (acute and chronic alcoholic insanities, acute mental 
confusion and delirium, some puerperal insanities, &c.). Between 
these two extremes of the series, however, two large intermediate 
groups exist, viz. (a) an imbecile (oligophrenic) group coming 
close to the idiocies in feeble evolution of brain and personality ; 
and (< b ) a somewhat different group, which I would, with Morel 
(20) and Magnan, term a degenerative group, with anomalous and 
irregular developments of brain and personality, which might 
well be designated paraphrenia (Maudsley [21] terms a large part 
of this group the group of insane deformities of kind). Members 

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SCIENTIFIC PSYCHOLOGY, 


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of this group (which includes several types) not only exhibit 
certain peculiarities of mind and conduct (intellectual, social, 
ethical), which stamp them as such (psychical stigmata), but also 
certain physical peculiarities of physiognomy, and of cranial and 
bodily conformation (somatic stigmata). These are naturally 
more marked in some groups than in others, the milder forms 
not demanding as a rule the more vigorous and drastic mea¬ 
sures of deprivation of liberty and asylum treatment, though 
these individuals give rise to a considerable amount of social, 
political, and moral danger. Finally comes the group which 
includes the wrecks and remnants of previous more or less 
severe and prolonged cerebro-mental disease, chronic derelicts 
after storms, deprived of their mental (intellectual, social, moral) 
equipments, and reduced to various low grades and levels of 
mental life—a highly motley, artificial, and lumber-room group 
really—the chronic dements ; these might, again, for conve¬ 
nience and uniformity of nomenclature, be called lipophreniacs . 

The tabulation of the various groups into classes and sub¬ 
classes gives the following scheme of the insanities, based upon 
fundamental facts of evolution, upon deep-seated affinities in 
connection with pathological findings, and upon facts of both 
aetiological and clinical import. It will be found that the clas¬ 
sification is a natural one, and at the same time practically 
useful: (the words used to designate the five main groups explain 
themselves). 


I. Aphrenia .—Arrests of cerebral (psychical) development 

with absence or deficiency of evolution of personality. 

(1 a ) Of somnolescent vegetative grade (many paralytic, 
hydrocephalic, and congenital idiots, helpless, wet 
and dirty, not educable). 

( b ) Of medium and higher grade (many microcephalic, 
cretinoid, epileptic, partially paralytic, or simple 
genetic idiots), slightly improvable and educable. 
(The higher grades approach to the next group.) 

II. Oligophrenia .—Enfeeblements and diminutions of cere¬ 

bral (psychical) development, with a parallel enfeeblement 
or diminution in the evolution of personality. 

(а) Imbeciles of lower grade ; not educable. 

( б ) Imbeciles of medium grade; partially educable and 


improvable. 


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1899*] BY W. LLOYD ANDRIEZEN, M.D.LOND. 285 

(1 c ) Imbeciles of higher grade; partially educable and 
improvable ; often with anti-social instincts. 

(d) Feeble-mindedness (so-called defectives) ; partially 
educable and improvable; often with anti-social 
instincts. 

III. Paraphrenia. —Anomalies and perversions of cerebral 
(psychical) development, with corresponding irregu¬ 
larities and deformities in the evolution of personality: 
(the milder forms are the so-called borderland cases 
between sanity and insanity). 

a. Paraphrenia Mitis .—Disharmonies of psychical develop¬ 

ment, with an unbalanced formation of the ego. Of 
mild type, e.g. eccentrics, cranks, mattoids, and some 
types of revolutionists, mystics, &c. 

b. Paraphrenia Gravis .—The graver anomalies and perver¬ 

sions of mind and personality. These include a 
variety of types, viz.— 

(1) With mental obsessions and irresistible impulses 

(e. g. agoraphobia, folie du doute, dipsomania, 
kleptomania, &c.). 

(2) With perverted (social) feelings, and delusions of 

rudimentary type (e.g. persecuted persecutors, and 
psychopaths of the litigious, erotic and jealous, 
mystico-religious, and other types). 

(3) With predominant perversion of moral and sexual 

nature (e.g. so-called moral insanity), sexual per¬ 
version (uranism, masochism, saidism), &c. 

(4) With predominant criminal and anti-social instincts 

(e.g. congenital criminals of the active type ; and 
imbecile criminals of the lazy type—neurasthenic 
type of Benedikt). 

(5) With hallucinations developing on an emotional 

basis, followed by systematised delusions and 
considerable transformation of personality (e.g. 
paranoia ; various sub-types). This is the “ delire 
chronique k Evolution syst^matique ” of Magnan. 

(6) With cyclic or periodic attacks of violence or 

mental confusion, or melancholic depression and 
agitation, or alternations of these phases (folie a 
double forme, periodic paraphrenia). 

(7) Associated with and modified by grave neuroses 

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286 SCIENTIFIC PSYCHOLOGY, [April, 


(e.g. epileptic, hysteric, choreic, hypochondriacal, 
and neurasthenic paraphrenias). 

(8) Associated with and evoked by the evolution of 
puberty or adolescence (< e. g. hebephrenia). 

IV. Phrenopathia. —Morbid conditions or derangements 
occurring in brains of nearly full cerebro-psychical 
development, and of apparent previous health (in child¬ 
hood or youth), with corresponding morbid alteration 
of the personality. 

(1) Vesanic type (e. g. melancholia, mania, stupor, acute 
mental confusion—asthenic confusion). 

(2) Toxic type (< e.g . alcoholic delirium tremens, mania k 

potu, chronic alcoholic insanities, lead encephalo¬ 
pathy, morphinism, cocainism, pellagra, ergotism). 

(3) Febrile micro-parasitic infectious type : some puerperal 

insanities, delirium acutum (so-called acute delirious 
manias), and serious delirium of influenza, scarlet 
fever, &c. ; acute cerebral meningitis ; tubercular 
meningitis. 

(4) Diathetic group: associated with a permanent and 

independent derangement of general bodily meta¬ 
bolism (e.g myxoedematous, goitrous, acromegalic, 
and possibly diabetic insanity ; post-syphilitic pseudo¬ 
paresis). 

(5) Chronic meningo-encephalitis , of progressive type (e.g. 

general paralysis of the insane). 

(6) Involutional: associated with involutional changes of 

middle and old age, e. g .— 

1. Chronic cerebral atrophy. 

2. Climacteric insanity. 

3. Senile insanity. 

(7) Traumatic: the “ cerebraux ” of Lasegue. 

(8) Neoplastic and thrombotic : following haemorrhages or 

multiple thromboses, neoplasms (glioma, sarcoma, 
&c.). 

V. Lipophreniaj: conditions of cerebral (mental) dissolution, 

with corresponding dissolutions of personality ; second¬ 
ary to previous insanities ; these comprise many and 
varied lines and groups, with different antecedents, but 
their common feature is the one terminus and goal to 


which they all tend. 


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1899 *] BY W. LLOYD ANDRIEZEN, M.D.LOND. 


287 


General Conclusions . 

(1) The doctrine of the localisation of functions in a central 
(nervous) organ is the basis which renders a study of psycho¬ 
logy and psycho-pathology possible ; such a central organ 
necessarily uniting within itself sensorial, kinaesthetic, and 
coenaesthetic functions. 

(2) The data of normal psychology should be supplemented 
by and collated with those of psychogenesis and pathology to 
constitute a practical as opposed to a speculative and meta¬ 
physical science. 

(3) The crude naturalism which gives rise to beliefs in 
subtle and mysterious “essences” and “principles” assumed 
to underlie physical, chemical, vital, and psychical phenomena, 
should be discarded. So should the metaphysical theories and 
dualism and monism be put aside as unsatisfactory, based on 
insufficient data, and foreign to the scientific method. 

(4) The capacities which simple protoplasmic organisms 
have (a) of being sensitive to incidental stimuli, and (J?) of 
responding thereto in definite ways, constitute “ feeling.” 
These capacities, subserved in protozoa by one and the same 
cell-body (as a rule), are associated in the metazoa with speci¬ 
ally developed elements constituting the nervous system ( e . g . 
medusa, starfish, &c.). 

(5) In the vertebrata a segmentation of the organism is 
found in the ancestral types (acraniates), and the nervous 
system shows a similarly formed chain-like structure or gan¬ 
glionic tube (bulbo-spinal axis). 

(6) The brain is developed at the anterior end of this axis, 
and is at the outset a simple aggregate of sensorial centres (a) 
of special senses, ( 6 ) of cutaneous and muscular sense, (c) of 
viscero-organic sense. As we rise higher in the vertebrate 
scale, other centres (adnexa or associating tracts and centres) 
are developed over and above these primary centres. 

(7) These secondary centres subserve functions of composite 
origin and complex nature, and also continue in a growing, and 
therefore less fixed and more plastic, stage for some time after 
the birth of the animal (mammals, man). 

(8) In the child’s brain (as in that of the kitten and other 
higher mammals) there is not only a quantitative growth in 
mass after birth, but a quantitative elaboration in complexity 

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SCIENTIFIC PSYCHOLOGY, 


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of structure and connections of the cortical nerve-cells. Mecha¬ 
nisms are thus formed which are capable of being trained and 
of being educated within certain limits. 

(9) The education of the nervous system begins after birth, 
when variations of the environment impress themselves on the 
child in countless numbers, and initiate the first marked varia¬ 
tions and disturbances in its sensorial, kinaesthetic, and organic 
life. The vegetative somnolescent life of the foetus is gradually 
replaced by one in which various sensations of intense and 
strong kind run through the brain, which are not yet recognised 
or clearly discriminated, and which produce confusion at first. 

(10) The “ law of psychogenesis ” is that development takes 
place not only in the sensorial and kinaesthetic centres, but in 
the psychical (relational) sphere which combines these two and 
follows definite lines ; and further that during these stages the 
child is peculiarly impressionable to surroundings. 

(11) The evolution of language as an instrument for the 
reinforcement of psychical activities (which, however, can take 
place in its absence) now co-operates greatly in brain develop¬ 
ment. It allows the child to represent the most varied and 
different things in terms of a common denomination ; it is that 
of the highest formal value in the exercises and repetitions of 
psychical processes which underlie mental evolution. 

(12) The gradual recognition of the empirical ego as the 
centre and source of spontaneous activities, and its distinction 
from and antagonism to the external world, are the bases of 
self-consciousness, self-assertiveness, and volition. The instincts 
proper to this stage are mainly egoistic (greedy, grasping, and 
parasitic), and largely dominate its acts and conduct. 

(13) As development goes on this stage is passed, the fore¬ 
brain, with its increased psychical and relation life, acts as a 
check to the purely vegetative functions and appetites, and a 
secondary (ethical) ego is developed which takes precedence 
(more or less) of the primary ego. Morality and conscience 
grow and assume priority. 

(14) With puberty and adolescence a new order of feelings 
and instincts (and the bodily organs related thereto) are largely 
and rapidly developed, causing a rearrangement and partial 
transformation of the ego. This stage is characterised also by a 
development of aspirations and sentiments towards self-sacrifice, 


altruism, and religion. 


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1 899.] BY W. LLOYD ANDRIEZEN, M.D.LOND. 


289 


(15) The “law of pathogenesis” is that many of these 
evolutions in brain and mind, from the foetal (vegetative som- 
nolescent) to the adolescent (sexually mature) stage, may 
undergo morbid alteration (perversion) or suffer defect (absence), 
and such pathological conditions of the brain are the bases of 
the insanities. 

(16) The insanities so regarded fall into groups which 
assume a serial and tree-like arrangement. At the lower end 
of the series come ( a ) the profound arrests (aphrenias, idiocies), 
and (< b ) enfeeblements (oligophrenias, imbecilities) of cerebro- 
psychical development At the other end of the scale are 
placed (d) the phrenopathies (e. g ; the vesariae, acute and 
chronic alcoholic insanities, general paralysis, climacteric in¬ 
sanity, &c.). Between these extremes comes (< c ) a “degenerative” 
group (the paraphrenias, obsessive and impulsive, vicious and 
criminal, paranoiac and hallucinatory, hysterical and epileptic, 
cyclic, and hebephrenic types). Fifth and last (e) come the 
lipophrenias, conditions of psychical dissolution, with corre¬ 
sponding reductions and degradations of personality, following 
upon and secondary to previous insanities. 


References. 


1. Mercier.— The Nervous System and the Mind. (Macmillan and Co., 
London.) 

2. Bevan Lewis. — Text-book of Mental Diseases, 1889 (Griffin). 

3. Hering. — Theory of the Capacity for “ Organic Memory ” of Living Proto¬ 
plasm. 

4. Compare Hadrian’s “Address to the soul by the dying person,”—a well- 
known little verse. 

5. Caird. — HegeTs Life and Philosophy (“ Philosophical Classics for English 
Readers ”). 

6. Max Werwarina. — General Physiology, or Science of Life. (English transla¬ 
tion, 1898). 

7. Lloyd Andriezbn. — Newer Aspects of the Pathology of Insanity (Brain, 
Winter, 1894). 

8. Binet. —Psychic Life of Micro-organisms. 

9. Max Verworn. — Psycho-physiologischen Protisten-Studien. 

10. Retzius. —Biologische Untersuchungen (vo s. i-iii). 

11. Topinard .—Anthropology; and Donaldson Growth of the Brain. 

12. Schiller. —On the Oculo-motor Nerve fibrrs, &c., in Donaldson (loc. cit., pp. 
163-171). Occasional karyokinesis in nerve-cells is very rare (Ziegler in 
Beitrage our Path. Anat., vol. i, part i, 1897) 

13. Vignal.— D&veloppement des Elements du Systbme Nerveux, 1889. 

14. Flechsig. — Gehirn und Seele, 1895 vi ie also Journal of Mental Science, 
January, 1899). 

15. Preyer. —The Mind of the Child. 

16. Dejerine. — Anatomie du Systbme Nerveux. 1896. 

17. KdLLlKER —Hand buck der Gewebelehre (Nervous System, part ii). 

18. Andriezen.— Loc. cit . (pp. 675-8). 


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290 


ACROMEGALY WITH INSANITY. 


[April, 

19. Flechsig. — Loc. cit., and Journal of Mental Science t January, 1899. 

20. Morel. — Trait 4 des Degenerescences Humaines , 1859. 

21. Maudsley. —Pathology of Mind, 1896. 


Acromegaly with Insanity. By David Blair, M.B., County 
Asylum, Lancaster. (') 

ALTHOUGH the condition of acromegaly existed and was 
described many years ago, its recognition as a morbid entity 
practically dates from the year 1886, when Dr. Pierre Marie, 
of Paris, named and defined it as a disease characterised by 
great overgrowth of the hands, feet, face, and head. Since 
then the disease, though rare, has been universally recog¬ 
nised, and more than 200 cases have been reported. Of 
these some have been typical, some atypical, and some have 
not been acromegaly at all. 

The following case, which has been under my observation for 
more than two years, besides being typical, has the additional 
interest of being associated with a well-recognised form of 
insanity. 

J. S—, a tailoress, was admitted to the Lancaster County 
Asylum on the 1st of May, 1891. Three months before 
admission some of her teeth had been extracted under nitrous 
oxide gas, which was the assigned cause of her insanity, and one 
month later she began to exhibit delusions. 

She persistently complained of a gas which pervaded the 
house and suffocated her. She charged certain people with 
maliciously causing it to enter. She maintained that she 
talked to people at a distance. She would walk about in front 
of her house with only her nightdress and boots on, and had 
to be brought in by the police. Four weeks before admission 
her delusions became so troublesome that she was constantly 
out of bed at night to search for the source of the gas. 

The patient was married and had four children. Only the 
youngest of these had survived, and was, at the date of admis¬ 
sion, nine years old. She had had no miscarriages, nor was 
there anything peculiar about any of her children. There was 
no hereditary predisposition to insanity, so far as known. 

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1899] 


BY DAVID BLAIR, M.B. 


291 


Though usually sober, quiet, and industrious, she had at times 
been intemperate. For six years menstruation had been 
irregular, and for some time she had been subject to head¬ 
aches. 

At the time of admission she was an unsightly woman with 
low forehead and coarse hair. Her nose, hands, and feet were 
very large. Her speech was slow, and she said that she could 
not use her needle so dexterously as formerly. Her bodily 
health was good: pulse 72, respiration 16. At night she 
usually curled herself up in a blanket and insisted on sitting 
on the floor. 

For several months after admission she worked well in the 
kitchens, but could often be seen with her head hidden behind 
her apron, or any other convenient article, to ward off the gas. 
She continued to complain of increasing and severe headache, 
and began to perspire heavily. She would weep, groan, wipe 
the perspiration from her face, and say “ See what they are 
doing with the gas! ” 

Antipyrin had no effect on the headache, but large doses of 
potassium bromide had some quieting influence by day. 

Her face became puffy, the hands and feet soft, spade-like, 
and swollen, as if myxcedematous. For a long period, there¬ 
fore, thyroid extract was given in beef tea. 

During the past summer I noted the following symptoms :— 
All the tissues of the hands are enlarged except the bones. A 
skiagram represents the bones as, if anything, less than normal. 
The result is a general hypertrophy in width and thickness, 
but the length from the wrist to the end of the middle finger is 
not increased. The feet are similarly affected. There is no 
pitting on pressure. The arms and forearms are of large size, 
but do not correspond in dimensions to the hands. The 
cranium is elongated in the antero-posterior diameter, and 
presents some hyperostosis along the margins of the inter¬ 
parietal suture. 

The face is elongated and oval, while the hypertrophy, of 
the nose and lower jaw especially, is slightly greater on the 
right side than on the left. The forehead is low, and supported 
on well-developed orbits. The eyes are relatively small and 
out of proportion to the size of the orbits. The lids are long 
and thicker than normal. The nose is the most hypertrophied 
part of the face. The alae are especially thickened, and en- 

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292 ACROMEGALY WITH INSANITY, [April, 

larged at their lower part. The upper lip is less hypertrophied 
than the lower, which is very prominent. The mouth is usually 
open, and the tongue, tonsils, and pillars of the fauces are 
hypertrophied. The voice is guttural and metallic. All the 
teeth which were not extracted have fallen out; they are very 
small. 

There is kyphosis of the spine in the cervical region, and 
the patient can hardly hold her head straight. Her favourite 
position is sitting with her arm on a table, and her forehead 
resting on her arm. All the tissues around the neck are much 
hypertrophied. The clavicles, ribs, and sternum are similarly 
affected. The abdomen is pendulous, while there is some lor¬ 
dosis in the lumbar region. There is profuse perspiration of a 
disagreeable odour. 

On an average she passes eighty ounces of urine in twenty- 
four hours. It is usually neutral or slightly acid in reaction. 
The specific gravity is usually as low as 1012, although on one 
occasion it was 1024. The urea is on an average *009 gram¬ 
mes per c.c. but 20*5 grammes per diem ; in other words, the 
percentage of urea is below normal, but the total amount 
passed in twenty-four hours approaches the normal. On the 
other hand, she takes more than the average quantity of nitro¬ 
genous food, so that practically less urea is excreted than under 
normal conditions. Occasionally there is a little albumen, but I 
have never detected peptones nor sugar. 

The most noteworthy feature about her urine is an excessive 
and persistent deposit of phosphates. As this deposit ceased 
when the patient was fed exclusively on milk, it is undoubtedly 
evidence of imperfect assimilation, and not of softening of the 
bones. 

The headache, though persistent, is more so at one time than 
another, and there are intermittent pains in the limbs and 
joints. 

The menstruation seems to have entirely ceased, but at 
irregular intervals of many months there are severe attacks of 
metrorrhagia. The patient is much given to masturbation. 
Intra-ocular pains are present, but the sight and field of vision 
are remarkably intact There is also at times a complaint of 
pain in the right ear. 

In association with this physical condition her mental sym¬ 
ptoms are most interesting. Her sense of humour is very 

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highly developed ; but her spirits are dejected and her temper 
irritable. There is a constant feeling of lassitude and a strong 
desire to recline; but though heavy and drowsy in appearance, 
sleep is disturbed. Until a few months ago she insisted on 
sleeping on the floor, as she said her bed was charged with 
electricity. She ascribes her headache, which of course we 
should refer to the pathological condition of the pituitary gland, 
to the presence of an electric battery in her head ; and to the 
electricity produced therefrom she attributes her intra-ocular 
and intra-auricular pains. She accounts for the pains in her 
limbs and joints by the spread of the electricity through her 
body. She indignantly denies she has a husband, and if 
any reference is made to him, flies into a fury. Her husband 
is alive, writes regularly concerning her, and says jealousy of 
him was a very early symptom in the case. When we reflect 
on the bitterness with which a woman once comely sees herself 
slowly degenerating into a hideous creature, we can appreciate 
these early suspicions which culminate in delusions. Her out¬ 
standing ugliness never fails to attract attention. As a result 
she is very distrustful with strangers, declines to converse with 
them, and is especially afraid of medical examination. At one 
time she heard voices at a distance, now she hears them under¬ 
neath the floor. She asks me to go down and I shall see for 
myself the gang of ruffians who are plotting to murder her, and 
have introduced this electricity into her system. These auditory 
hallucinations arrive not only through her ears but also through 
her body by means of the electric wires, and are most intense 
by night, although they are also heard by day. The original 
delusions regarding gas have been replaced by delusions regard¬ 
ing electricity. The perversions of general sensibility cause the 
patient great distress. She has pains all over, feels as if people 
were constantly pricking her with needles. 

She imagines every one is quite aware of her condition, and 
when asked about her hallucinations says testily, “ I am sure 
you know well enough without asking me.” 

Finally, she has pronounced delusions of grandeur. She asserts 
that the asylum and the land around it belong to her ; that she 
has been left large estates in Ireland, and that she is possessed 
of great wealth. When the slightest doubt is cast on these 
assertions, she replies, " you’ll see by-and-by.” There is no 


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294 ACROMEGALY WITH INSANITY, [April, 

dementia. Her intelligence and mental acuteness are above 
the average of her class. 

In this description of mental symptoms I think there is to 
be read a typical case of persecutory mania. And it is inter¬ 
esting to note that while the hallucinations are the insane 
interpretations of pains in the head, ears, and limbs, and 
alterations of general sensibility due to the acromegaly, that 
these are the identical hallucinations with which we are most 
familiar in cases of persecutory mania, of which the pathological 
basis is purely problematical. And still further it is to be 
observed that in this case there are in operation all those phy¬ 
sical causes to which persecutory mania is by most recent 
writers referred. Mental causes are now believed to play an 
unimportant part in its production ; they act only indirectly 
by lowering the vitality. 

The physical causes of persecutory mania are divided by 
Ritti into three classes. (i) Causes which act on the brain and 
nervous system. Of these we have here the implication and 
perversion of function of the pituitary gland, the exact signifi¬ 
cance of which we shall see later. 

(2) Those causes which have their origin in the reproductive 
organs or in sexual life. In this case we have the early appear¬ 
ance of amenorrhcea with the subsequent attacks of metrorrhagia 
and masturbation. 

(3) General causes of physical debility, such as insufficient 
nutrition. Acromegaly is essentially a disease of malnutrition. 
In short, this is a case of persecutory mania in which we may 
point to the direct physical causes. 

Of the aetiology of acromegaly itself we are practically igno¬ 
rant. In these cases, where an exciting cause has been 
suggested, alcoholism seems to be the most frequent. It 
attacks every race, males and females, nearly equally, and it 
may occur at any age ; but the majority are seized from 
twenty to forty years of age, although it most probably begins 
to develop shortly after puberty. 

Of the diseases with which acromegaly has been confused, 
the two most common are myxcedema and hypertrophic osteo¬ 
arthropathy. This confusion is increased by the fact that 
acromegaly has been described in connection with both. 

From the former it is differentiated by the fact that in acro¬ 
megaly the bones are always implicated, while in myxcedema 

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BY DAVID BLAIR, M.B. 


295 


there is no enlargement of the bones. In addition to this 
salient distinction, other points of difference are so numerous 
that a well-established case of acromegaly could now-a-days 
hardly be confused with myxcedema. 

From hypertrophic osteo-arthropathy acromegaly is dis¬ 
tinguished by the fact that in the former only the bony tissue 
is enlarged, and that especially at the articular ends of long 
bones, whereas in acromegaly both the bony and soft tissues 
are increased. Again, in hypertrophic osteo-arthropathy the 
symmetry of the hands is destroyed by enlargement, prin¬ 
cipally at the joints and ends of the fingers, whereas in acro¬ 
megaly the hands and fingers are enlarged universally and 
symmetrically. 

Both Marie and Souza-Leite point out that acromegalics are 
far from being giants. Yet the disease is frequently confused 
with gigantism. While there is no reason why acromegaly 
should not occur in a giant, it has nothing to do with the 
height of the individual. The majority of acromegalics are not 
above middle height—the case under discussion is only five 
feet one inch—while a perceptible diminution in size has been 
observed in some after the onset of the disease. 

In the latest issue of the Journal of Mental Science , Professor 
Joffroy is said to have described a case of acromegaly, and to 
have considered gigantism to be the same disease as acrome¬ 
galy, only occurring before adult life—that is, during the period 
of growth. I do not know Professor Joffroy's reasons for this 
contention, but I fail to see how the proportions of the limbs 
and face would preserve their relationships to each other before 
adult life any more than after. Some cases of acromegaly 
have been described before adult life. The appearance of 
gigantism is never that of acromegaly. Gigantism is only an 
exaggeration of a normal process ; acromegaly is a true 
disease. 


Dr. Middleton, of Glasgow, has described a case with trophic 
lesions of the joints, like Charcot's joint lesions in locomotor 
ataxy. In the same case Raynaud's phenomena occurred in a 
minor form, and there was a tendency to erysipelas. And in 
the forty-seven autopsies collected by Sternberg, of Vienna, in 
his recent monograph, and quoted by Fumivall, there was 
degeneration of the spinal cord in four, in Goll’s column especi¬ 


ally in two, in Burdach's column in one, and of the peripheral 

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296 


ACROMEGALY WITH INSANITY, 


[April, 


nerves in one. Such are further indications of the profound 
trophic disturbance which must be at the root of the disease. 

The structures to which most importance is attached in the 
pathology of the disease are the pituitary body, the thyroid and 
thymus glands, and the sympathetic nerve ganglia. 

In the table of forty-nine cases compiled by Furnivall, chiefly 
from the collection of Sternberg, the sympathetic ganglia were 
observed in thirteen. Of these six were normal, six were 
hypertrophied, and one was hypertrophied with degeneration. 

The thyroid gland was observed in twenty-nine cases. Of 
these only five were normal, thirteen were hypertrophied, while 
the others showed various forms of degeneration. 

The thymus gland was observed in nineteen cases. It was 
found to be absent in seven, hypertrophied in three, persistent in 
eight, left lobe hypertrophied in one. 

Cases of acromegaly have been described in which it is said 
that no change in the pituitary gland occurred. This is very 
doubtful. 

In 1895 Professor Tamburini described a case of acromegaly, 
and discussed the pathology of the disease. Up till then, so 
far as he knew, only twenty-four cases were described in which 
post-mortems had been made. In seventeen of these, all of 
which were typical cases, a tumour of the pituitary was found. 
Out of the other seven he disposed of five as not having been 
cases of acromegaly at all. In the remaining two the disease 
had only been of brief duration, while the absence of structural 
changes was not established by microscopical examination. 

In the whole of the forty-nine cases quoted by Furnivall, the 
pituitary gland was hypertrophied or the seat of a lesion. We 
may therefore conclude that the most constant organ to show 
disease in acromegaly is the pituitary gland. This lesion may 
take the form of hypertrophy, tumour, cyst, or other degenera¬ 
tion, and it is generally believed to be the most important aetio- 
logical factor. This constant lesion of the pituitary gland as a 
concomitant of acromegaly has brought that body into special 
prominence. It was, of course, known that it consisted of two 
lobes, of which the anterior is the larger, and concave behind 
where it embraces the posterior smaller lobe. It was likewise 
known that the two lobes are entirely different both in structure 
and development, yet their functions were practically unknown. 
Of late years some light has been thrown on this subject. 

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1899] 


BY DAVID BLAIR, M.B. * 


297 


At the Annual Meeting of the British Medical Association 
in 1893, Andriezen read a paper giving results of researches 
on the morphology and evolution of function of the pituitary 
body. He showed that the subneural gland in larval Amphioxus 
is the analogue of the pituitary gland in higher animals and in 
man. He believes it to be a complex organ composed of three 
parts : (a) an anterior secreting glandular organ ; ( b ) a water- 
vascular tube lined with ciliated epithelium and connecting the 
buccal cavities with the ventricles and the rest of the neural 
cavities ; and ( c ) a posterior sensitive nervous lobe. The last 
two are well developed and functionate in ancestral vertebrata, 
but become obliterated and atrophied in function and structure 
in all forms above larval acraniates and Ammoccetes. The 
anterior lobe—the glandular secreting portion—is the type of 
a secreting structure of epithelial cells arranged in lobules and 
acini with many ducts opening into one principal duct. Its 
secretion is carried with the water-vascular stream through the 
central nervous system. The function of that secretion must 
be either trophic, acting on the nervous tissues, or destructive 
and neutralising waste products of nervous tissues. 

In man the water-vascular system has given place to a 
blood-vascular, and the duct of the pituitary gland is closed. 
But the secretion of the pituitary is needed just as much after 
the closure of the pituitary duct and the cessation of the water- 
vascular system. The only difference is that the oxygen 
which was provided for the nervous system by the water- 
vascular system is now provided by the blood-vascular system. 
Hence the pituitary gland continues its secretion after the duct 
is obliterated and after it becomes ductless. The secretion is 
internal and absorbed by the lymphatics. 

But it is not on the grounds of evolution alone that the 
function of the pituitary is believed to be that of internal 
secretion. In its microscopical structure the anterior lobe of 
the pituitary bears a resemblance to another internal secreting 
gland—the thyroid body, and a colloid substance like that in 
the thyroid vesicles is found sometimes in the alveoli of the 
anterior lobe of the hypophysis. Rogowitsch observed that 
the blood-vessels of the pituitary contain something besides 
blood, which he assumed to be colloid ; Pisenti and Viola 
showed that it is colloid matter. Extirpation of the thyroid 
causes structural alteration of the hypophysis, and pathological 

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298 


ACROMEGALY WITH INSANITY, 


[April, 


alteration of the latter has been found in cases of lesion of the 
thyroid. Louis Compte, the most recent writer on the relation¬ 
ship between the functions of the pituitary and thyroid glands, 
concludes from the examination of 100 miscellaneous cases 
that these organs act vicariously. Drs. Boyce and Beadles, in 
the Journal of Pathology for March, 1892, describe two cases 
of myxcedema with hypertrophy of the pituitary body, and in 
one of these there was a striking increase of pituitary colloid. 
Dr. Beadles reports three fatal cases of myxcedema in the 
Journal of Pathology for 1898, in all of which the pituitary 
body was above the normal size and weight. 

In a case of myxcedema at present under my care in which 
the symptoms have only been kept in abeyance by the almost 
constant administration of thyroid extract, I have obtained the 
same result with pituitary extract. 

Still further, experimental destruction of the gland has been 
followed by notable results. The organ has been successfully 
removed both in dogs and cats. In all cases of complete 
removal death results, usually within a fortnight of the opera¬ 
tion. The symptoms observed are (1) a diminution of the 
body temperature; (2) anorexia and lassitude; (3) muscular 
twitchings and tremors developing into spasms ; (4) dyspnoea. 
Many of the symptoms show abatement after the injection of 
pituitary extract. The investigators Vassale and Sacchi con¬ 
clude that the pituitary must furnish an internal secretion 
which is useful in maintaining the nutrition of the nervous and 
muscular systems. 

But although the pituitary and the thyroid glands are to 
some extent vicarious, they are certainly not identical. For 
just as the disease associated with perversion or suppression of 
function of the pituitary differs in its clinical features from 
myxcedema, so do the effects of experimental injection of the 
extracts of pituitary and thyroid materially differ. 

Thyroid extract causes dilatation of arteries and consequent 
fall of blood pressure without diminishing the heart's beat. 
Pituitary extract increases the contraction of the arteries and 
the heart, giving rise to marked increase of blood pressure. 
Moreover, in myxcedema thyroid extract is of the greatest 
benefit; in acromegaly it is of little value. 

According to Shattock there is considerable ground for 
believing that both glands have more than one function, but 

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BY DAVID BLAIR, M.B. 


1899.] 


299 


that they have at least one in common, namely, their colloid- 
producing capacity. 

The two glands are vicarious only as to what they have in 
common, and thyroid and pituitary extracts can be of service 
in disease of the converse gland only pro tanto. 

Virchow suggested that in acromegaly we have described 
only half a disease—the latter and degenerative half. This 
does not seem improbable. For although in a case recorded 
by Duchesneau progressive muscular atrophy preceded the 
development of the acromegaly, some cases in the beginning 
seem to have an increase of muscular power. 

Such a state of matters might possibly mean that there is an 
increase of secreting cells in the pituitary with consequent 
increase of function during the period preceding degeneration. 
And so in the treatment of the disease there would be a period 
when pituitary extract was contra-indicated as well as a time 
for its administration. Just as in the treatment of Graves’ 
disease, which is believed to be due to a hypersecretion on the 
part of the thyroid gland, the thyroid treatment has been found 
to aggravate rather than to allay the morbid phenomena, as 
opposed to its great value in myxcedema, in which the thyroid is 
shrivelled or completely atrophied. 

The treatment of acromegaly has been so far chiefly sympto¬ 
matic. Pituitary and thyroid extracts have been tried in many 
cases, but with very doubtful results. 

Thyroid extract is not entirely useless. Its most constant 
effect is to reduce the body weight, and it may produce slight 
physical and mental improvement, as in the case reported by 
Dr. Neal. 

Treatment by pituitary extract seems to have been rarely 
tried. In a few cases negative results have been reported. 

Cyon, however, on the 28th November, 1898, communicated 
to the Paris Acad^mie de M^decine a contribution to the treat¬ 
ment of acromegaly by hypophysin. He reported the case of 
an obese acromegalic in whom seven weeks* treatment diminished 
the weight by nine kilogrammes, and the circumference of the 
abdomen by 3 5 cm. The pulse became regular, and the head¬ 
ache, nystagmus, and intellectual apathy were improved. 

Last September I began giving the case under my care 
pituitary extract. During the first month 74 gr. per diem were 


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ACROMEGALY WITH INSANITY, 


300 


[April, 


distributed in three doses. The amount was then increased to 
15 gr., and after a fortnight to 19J gr. 

The first pronounced effect was a severe onset of metrorrhagia 
accompanied by haemorrhage from the bowel. This passed off 
in a few days, and a marked improvement in the patient’s con¬ 
dition set in. Her irritability and drowsiness almost vanished. 
She went to bed willingly and slept all night. She became 
very amiable and useful in the hospital, while she developed 
great ingenuity and activity in making and dressing dolls. 
She was induced to go to entertainments, and began to read 
solid literature. 

The month before treatment was commenced she weighed 
12 st. 3 lbs.; one month after treatment was begun, 11 st. 
11 lbs.; two months after treatment was begun, 10 st. 7 lbs. 
At the end of two months the extract was withheld, and she 
began to increase again in weight. 

A few weeks after treatment was begun her urine was found 
to be reduced in quantity from an average of eighty ounces per 
diem to fifty-nine. There has been no diminution in her appe¬ 
tite, and she has menstruated about once a month since treat¬ 
ment was begun—a condition which has not existed since her 
disease began many years ago. 

Encouraged by these results, I have tried the effect of pituitary 
extract on two cases of myxoedema. In one severe headache 
and sickness occurred, so it was promptly stopped. In this 
case, too, thyroid extract appeared to have no effect. In the 
other, which has been previously referred to, the patient said 
she derived great benefit, and it certainly appeared to act as a 
physical and mental tonic. I have tried the effect of pituitary 
extract on several cases of insanity, but as a rule with negative 
results. In one case at least, in whom insanity was associ¬ 
ated with irregular and scanty menstruation, mentalisation 
became less sluggish, dirty habits ceased, the patient began to 
read and play on the piano, her menstruation became re-estab¬ 
lished, and her general improvement was marked. 

Acromegaly appears to be extremely rare in asylums ; in fact, 
the only other undoubted case I know to have been in a British 
asylum died at Colney Hatch in 1885. It was under the care 
of Dr. Robert Jones, who was medical officer there, and, 
although the disease had not then a name, yet Dr. Jones’s 


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BY DAVID BLAIR, M.B. 


1899.] 


301 


clinical and post-mortem notes at the time leave no doubt of 
its nature. It has been reported by Dr. Beadles. 

From the Continent two cases have been recorded, to both 
of which casual reference has already been made. One of 
these occurred in an Italian asylum under Professor Tamburini, 
another in a French asylum under Professor Joffroy. 

The problem of acromegaly is still unsolved. But, despite 
its rarity in asylums, its future physiological developments 
will be fraught with interest as great for the mental physician 
as for any other class of medical men. 


Discussion 

At General Meeting, Chester, 1899. 

Dr. Robert Jones said he had charge of a case in 1884, just a year before M. 
Marie described the malady. There was then much uncertainty as to the exact 
diagnosis. He got several of his colleagues from St. Bartholomew’s to see the 
patient. The woman was distinctly ugly. She had thickened lips, a large lower jaw, 
a very dull look, and frequently complained of rheumatic pains. She passed large 
quantities of urine. No one was able to give the disease a name. The patient even¬ 
tually died from gastric haemorrhage, and a very marked tumour was found replacing 
the pituitary body. Since then two hundred cases had been reported. The last he 
saw was a man in the Isle of Wight, at Ryde, who he believed was still at his 
occupation in a bicycle shop. As Dr. Blair said, there were probably more cases 
outside than inside asylums. He thought it was borne out by experience that the 
most constant change was observed in the pituitary body. 

Dr. W igglesworth said it was somewhat doubtful whether the insanity was in 
this case dependent on the acromegaly or on previous alcoholic intemperance, 
which last was a very much more common cause. As far as he knew there had 
been hardly any similar cases recorded. There was no doubt that the pituitary 
body had been found diseased in a large number of cases, and the conclusion had 
been reached that that was the cause of the disease. He thought the proof of that 
was not yet complete. They had negative cases as well as positive. He remem¬ 
bered a case in which the pituitary body was extensively destroyed by a tumour of 
slow growth, yet there was no acromegaly. 

Dr. Mercier said it might be true that the pituitary body might be diseased 
without acromegaly, yet for all that acromegaly might be the result of a particular 
pathological affection of that body. They knew that defects in the supra-renal 
bodies might occur without the ordinary appearances of Addison’s disease; but 
they knew that Addison’s disease was invariably associated with and dependent 
upon a defect of the supra-renal bodies. He should be glad to give the members of 
the Association an opportunity of seeing a typical case of acromegaly at no great 
distance from Dartford. 

Dr. Nicolson said that he would be most interested to know whether the 
condition that gave rise to the enlargements arose from the existence of some 
specific detrimental material supplied to the tissues, or from the want of some 
corrective material in the nutriment of those particular tissues. By getting at the 
commencement of the destructive changes or the pituitary body, and by investi¬ 
gating the peripheral portions where the enlargement took place, they might be 
able to find out cause and effect. 

Dr. Campbell said that he had seen two cases of tumour of the pituitary body. 
In neither were there acromegalic changes, but he had no desire to criticise the views 
expressed. 

Dr. Whitcombe said a case came under his notice lately: a young man 28 years 
of age, who was an epileptic, and whose disease was diagnosed before admission to 

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302 


DEGENERATIVE SYPHILITIC INSANITY, 


[April, 


the asylum. He certainly was in the early stage of this disease, as his appearance 
entirely concurred with that which they had heard from Dr. Blair. He regretted 
that post-mortem examination could not be obtained. 

Dr. Blair, in reply to Dr. Wigglesworth, said it was very difficult to find out 
exactly whether the woman drank to excess or not. They had information that at 
times she was a little intemperate; but he did not think her insanity was due to 
alcoholism. Acromegalics nearly always in the end became demented; but he did 
not know of any other case in which there had been an acute form of insanity. 


A Degenerative Form of Syphilitic Insanity , with 
Clinical Types . By G. A. Welsh, M.D., Assistant 

Physician, Crichton Royal Institution, Dumfries. 

As an introduction to this paper I have detailed three cases 
as clinical pictures. My conclusions are based on an examina¬ 
tion of sixteen cases, six of which proved recoverable. Case 
No. i is an example of recovery and illustrates the condition 
found ; but it presented no congestive attacks, which some¬ 
times occur during the course of such a case. Cases Nos. 
2 and 3 show in addition confirmed muscular and degenerative 
lesions precluding any chance of recovery; in both, however, 
there were distinct remissions. 

Before passing to general considerations I have formulated 
in a few sentences the points to be considered. This malady 
is a degenerative condition of the nervous system primarily 
attacking the nerve-cells. It closely resembles general para¬ 
lysis in its clinical manifestations. The progress, however, 
shows that in some cases the disease is curable ; in others, 
which do not permit of cure, alleviation in the form of remis¬ 
sions can be obtained by antisyphilitic treatment. These 
cases which progress follow closely that progressive degeneration 
known as general paralysis. 

In studying this form of nervous degeneration the first ques¬ 
tion to be considered is, “ How does the virus act in producing 
the nervous disorder ? ” The clinical phenomena give evidence 
of a degenerative process, and point to the presence of an irrita¬ 
tive lesion of nerve-cells (mental and motor). What then is 
the irritant, and what is the modus operandi ? The irritant, I 
believe, is a toxine produced by syphilis ; and in using this term 
toxine I have done so in its widest significance. The evidence 

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1 899-] 


BY G. A. WELSH, M.D. 


303 


of toxine formation in syphilis is shown by the clinical mani¬ 
festations of the disease, more conclusively in the non-nervous 
and early lesions which are infectious by the glandular secretions 
than in the late and non-infectious lesions. It may be that the 
toxine through time changes its composition, losing its infective 
power, while it retains its virulence for the already infected 
organism. This toxine, whether it be a toxalbumin, an 
albumose, or a ptomaine in composition, is a highly noxious 
substance, and prevents and perverts healthy cell life in the 
various tissues of our economy. 

The question of the action of irritants on nervous tissue calls 
up a large field, and to put it shortly we find that the substance 
may be introduced from without, e.g . alcohol, cocaine, morphia, 
&c.; or it may be formed within, e.g. toxine formation in 
influenza, diphtheria, beri-beri. It matters not whether it is an 
introduction from without or a formation within, the common 
action of an irritant is always present, though the manifestation, 
degree, and ultimate end may vary. 

Dr. Marinesco in his recent experiments has proved that 
there is a selective affinity manifested by irritants; certain 
toxines act on certain cells, and have the power of singling out 
different parts of the chromophile elements for their special 
action. 

I cannot at present venture any opinion about a selective 
affinity for any special part of the chromophile arrangement on 
the part of the syphilitic virus ; all I am able to state is that it 
affects mental and motor cells. 

Before proceeding further I want to make clear, 1 st, that 
this is a manifestation of the tertiary stage; 2nd, that it is 
a degenerative lesion, and one distinct from formative change. 
The formative lesions have their origin in the mesoblastic con¬ 
nective and supporting structures, including the blood-vessels ; 
the degenerative attack the specialised tissue of the paren¬ 
chyma. 

This brings me to consider briefly some points which have a 
bearing on the question of cell degeneration, and which I shall 
describe under the heading of “ The Specialisation of the Cell.” 
Jt is well known that when a part of the parenchyma of the 
brain becomes destroyed it is not reproduced by division of the 
healthy cells ; the loss of tissue is largely compensated for by an 
hypertrophy of the neuroglia and connective tissue. This is 

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304 DEGENERATIVE SYPHILITIC INSANITY, [April, 

proved by the microscopic appearances in general paralysis, 
and in cases where the process has been acute and has caused 
destruction of cells. In these cases we find that the number of 
cells is diminished, that many of the cells are .atrophied, and 
that there is a hyperplasia of the neuroglia and connective 
tissues. This, we find, is the general law governing all special¬ 
ised tissue ; there is no replacement of destroyed cells. When 
we consider the process of disease in a tissue which is not 
specialised, e. g. the various connective tissues, we find that the 
cells not affected by the disease reproduce and multiply to form 
a tissue similar to that destroyed. The conclusion we draw is 
that when there is cell specialisation the vegetative function of 
reproduction is replaced by the special function which the cells 
take on ; surely we have a pre-eminent right to say that this is 
true of the highly specialised tissue which forms the nervous 
system. This is the conclusion M. Marinesco has come to 
about the brain cell; his idea is that in acquiring its special 
function the nerve-cell has lost its vegetative faculty of repro¬ 
duction. 

It could not be otherwise, because, stored in these cells, we 
have our ideas and memories, and if they were constantly 
dividing and multiplying, these memories and ideas would 
indeed have a precarious existence. Clinically we find that 
when destruction of nerve-cells occurs in the motor areas, and 
still more so when it takes place behind these areas in the 
sensory part of the brain, it causes permanent impairment in 
the form of mental weakness, with its accompaniments—loss 
of initiative ideas, control, and in many cases loss of memory. 

The important points next to be considered are arrest in the 
process, and progressive degeneration. When once a process 
of disease produces a gross or permanent change in the nervous 
system, owing to the intimate correlation of its component 
parts, and its sympathetic and sensitive structure, it necessarily 
is progressive, and spreads to a greater or less degree. If it 
can be arrested, or if it be checked, by the vis medicatrix 
naturce , and does not go on to a gross or permanent change, 
the tissue may and can recover its wonted vitality. There is 
no question of a production of new tissue to compensate for 
the destroyed cells : it is a case of life or death of the affected 
cells. In syphilitic degeneration of nerve-cells arrest is the 
exception rather than the rule, and only rarely do we get it ; 

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30S 


still I have seen and heard of undoubted cases, and some 
explanation is required. The resistive power of the cells must 
be considered, the intensity of the virus, the question as to 
whether it is in action alone, and the general state of the 
nervous system ; but in all cases the personal equation comes 
markedly before us, and it is next to impossible to say whether 
or not a case is going to recover. The resistive power of the 
cell is lowered by many factors. First, by what I have called 
a slow degeneration. This depends upon the presence of the 
toxine, and it is highly probable that it is a chemical and 
molecular alteration. To explain this slow degeneration in 
the case of the spinal cord, Edinger has advanced a theory. 
He says that those parts of the cord which, being constantly in 
use (muscular sense, equilibrium, motion), undergo most waste 
and repair, are more readily affected by anything that tends to 
interfere with such repair—for example, a syphilitic toxine. Their 
frequent use will, with such interference, lead to exhaustion and 
decay. I would apply the same theory to the nerve-cells in 
the brain ; the toxine interferes with the chemical changes in 
the protoplasm of the cell, and causes slow degeneration. 
There seems to be no particular affinity for the cells it^attacks, 
motor and sensory cells alike suffer from its action. This 
seems to be proven in the lower trophic realm by the sensory 
ataxic and spastic symptoms found in cases with spinal 
lesions. 

Second, the intensity of the virus. Syphilis is an uncertain 
creditor, in some cases exacting slightly and in others exacting 
to the full. 

Third, the question as to whether it is in action alone. I 
believe that syphilis can of itself produce nervous disease, 
but that the cases where it does so are rare; generally we find 
that we have to do with both syphilis and alcohol, especially in 
the degenerative variety. This combination of toxines is bound 
to be a more serious matter. 

Lastly, the general state of the nervous system. By this I 
mean the presence or absence of confirmed change, e. g. vas¬ 
cular change in the larger vessels, and tract degeneration in the 
cord or in the optic tracts. A pathological change of this 
nature in the nervous system is of the highest importance, 
because of that perfect connection which causes co-ordinate 
action, and because of the tendency to a far-reaching degenera- 

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DEGENERATIVE SYPHILITIC INSANITY, 


[April, 


tion. This fact is prominently brought before us in gross 
changes, because we have a pathological basis and connection, 
and are able to follow centripetally or centrifugally from the 
seat of the lesion the changes known as nervous degeneration. 
The existence of such a change of necessity almost precludes 
any chance of permanent recovery, and makes for progressive 
degeneration. 

The other pathological conditions of microscopic vascular 
and neurogliar change I mention to show that I have them in 
view. They are not, to my mind, of primary importance, being 
results of the cell change rather than causes. It may be men¬ 
tioned, however, that small cortical softenings, the result of 
ruptures of miliary aneurisms, are sometimes found. These 
rank as being on the border-line, and as producing permanent 
change. 

Having finished these considerations, I can now pass to the 
study of the condition when an actual breakdown has taken 
place. This is ushered in by an active change, with signs of 
cerebral irritation and congestion. The length of time the 
toxine has been in action before the active change takes place 
is, with our present knowledge, impossible to state, but there 
are modifications in the clinical appearances which lead me to 
think that it must have been for some considerable time. 
How long I cannot say definitely; months certainly, and in 
some cases years. This brings me to an interesting though 
difficult question to settle, viz. “ What is the part which the 
toxine plays when the active change is set up ?” There is no 
reason to doubt that it is still in action, but I do not think 
that its action is so important. It may be that the active 
change acts as a break in the process of slow degeneration, 
and if resolution takes place, permits of cure, because there is 
no doubt that those cases subacute in origin and course, invari¬ 
ably pass into a progressive degeneration. I do not think it 
likely that this change owes its continuance to the action of .the 
virus ; rather I incline to the view that here we have an active 
change in nerve-cells, already damaged, which cannot and does 
not subside for a considerable time in recoverable cases. The 
casual factors concerned in the active change seem to be added 
to the toxine, the result being produced by a combined 
action. I have enumerated them as alcohol, sexual excess, 
mental worry, and brain exhaustion. In none of the cases 

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I have seen could all of these be eliminated, and the question 
to be decided is, “What part do they play?” We must 
study their action, first, in the relation to the nerve-cell; 
second, in relation to the blood-vessels. All act as stimulators 
and irritants of nerve-cells, and if we take alcohol as an 
example, we can formulate points common to the others. 
Speaking generally, its action on the cerebral cells is to produce 
an inhibitory and paralysing effect on cell metamorphosis. By 
such an alteration a condition of auto-intoxication is set up, 
which explains the irritating and stimulating action. The 
smaller capillaries become dilated, and congestion of the part 
follows. 

This brings me to the question, “ What is the pathology ? ” 
I have already stated that I believe there are two stages, 
1 st, a slow degeneration ; 2nd, an active change; but beyond 
this at present I cannot go. In recoverable cases the obser¬ 
vations have to be clinical, and in those which progress death 
rarely takes place till an advanced stage of degeneration is 
reached. It is not improbable, from Dr. Marinesco’s recent 
experiments, that the active change is ushered in by a chroma- 
tolytic process, but this takes me into the field of hypothesis 
and away from definite pathology. 

Before passing from this, however, there is one other point 
requiring mention, viz. “ that there is in syphilis a strong 
tendency for the vis medicatrix naturce to assert itself and 
produce a spontaneous cure : this fact forms a strong adjuvant 
to medical treatment.” 

Lastly, there are certain aspects and phenomena which are 
purely clinical. 

The term syphilitic insanity, as applied to degenerative cases, 
is condemned by many authorities, but there are certain con¬ 
siderations, especially the results of therapeutic treatment, 
which I think justify the inclusion of these cases. 

Heredity .—What is the relation of heredity ? I think it is 
indirect, and is best explained by saying that the patient has a 
neurotic temperament, or, better still, that he is of the neuro¬ 
pathic diathesis. The person shows a predominance of nervous 
energy ; he is intellectual, cultured, and fond of any pleasure 
which requires mental energy and activity. The nervous 
system, in his economy, is the one where pressure is always 
high, and where a breakdown is most liable to occur if the 

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DEGENERATIVE SYPHILITIC INSANITY. 


[April, 


process of repair is in any way interfered with. His nervous 
system is highly sensitive, and reacts in a marked manner to 
any outside stimulus. 

Symptomatology .—The symptoms found are distinctive. 
The disease is one which admits of definition, and may be 
defined as a disorder of the nervous system, characterised by 
mental symptoms with motor accompaniments. In every case 
there are motor accompaniments, and I do not consider that 
without them the case can be included in this form. The 
mental condition is that of exaltation with excitement, and 
might well be called syphilitic mania. 

The premonitory stage is short in duration, and in the cases 
I have studied varied from ten to twenty-one days. It is 
marked by a change in manner, irritability, eccentric acts, rest¬ 
lessness, and insomnia. It varies greatly in the intensity of its 
manifestation, and in some cases is so slight that it passes 
without attracting attention. 

The stage of invasion is acute in its onset, and is character¬ 
ised by mental exaltation with delusions of grandeur, and in 
some cases, in addition, with delusions of suspicion and perse¬ 
cution. This mental manifestation is described by many 
authorities (Savage, Meikle) as a rare condition. Some differ¬ 
entiate between the grandiose delusions found in syphilitic 
disease and those found in general paralysis, but in the cases I 
have seen no difference in the nature or character of the 
grandiose ideas could be detected. The delusions of suspicion 
and persecution play a secondary part, and merely corroborate 
the fact that they are commonly found in the insanities of 
toxic processes. Of the other mental manifestations which 
also occur in ordinary cases of mania there are certain which 
require special note. ist. Sleeplessness. 2nd. The degree of 
mental enfeeblement. 3rd. The variability and alternation of 
the mental condition. 4th. The occurrence of remissions. 

Sleeplessness with restlessness and uneasiness is generally 
marked, especially in the early stages. This shows that the 
cell change and capillary engorgement are active. It is a 
symptom which requires active treatment, as its continuance is 
bound to aggravate the cortical condition. To put it shortly, 
the sleeplessness is caused by the active condition, but its 
continuance means a fresh irritant to the already damaged 


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The mental weakness is marked in every case from the 
beginning, and is out of proportion to the durati6n of the acute 
change. It shows itself in the extravagance of the delusions 
and the facileness. Impulse is considerably modified, the 
mental element of the mento-motor act is strong, but the motor 
is weak, and what the patient does is to talk much and do 
little. I have not seen one case where it was a suicidal impulse. 
It is interesting to note that in simple acute alcoholic mania 
suicidal impulse is common ; in this disease, where alcohol 
frequently acts as a causal factor, we do not seem to get it. 

Two explanations may be put forward to account for this 
modification of impulse : 1 st, the syphilitic factor may modify 
it; 2nd, it may be due to the paretic motor condition found. 

The variability of the mental condition is a prominent 
feature. It varies from a passing instability to a marked 
alternation ; a period of excitement lasting for days or weeks is 
followed by a period of depression. This condition I find 
helpful in forming a diagnosis. 

The Occurrence of Remissions .—Periods of remission occur 
during the course of curable cases. They are, however, more 
marked in those progressive cases under antisyphilitic treat¬ 
ment, and show the beneficial result of that treatment. In 
such a remission I have known a professional man carry on his 
work for six months. 

Motor Signs .—They are invariably present, and show a 
paresis of motor power and a diminution of reflex excitability. 
Diminution of kinetic power is a marked contrast to the active 
mental state, and is not what we expect. The actual conditions 
I find are—1st. Paresis, local or general. 2nd. Paretic inco¬ 
ordination, which, as a rule, is limited to the lower extremities 
but sometimes affects the upper. 3rd. Absence or diminution 
of the knee and other tendon reflexes. 4th. Muscular tremors, 
and defective articulation of speech in the form of paretic 
slurring. 5 th. Regular congestive attacks sometimes occur 
during the course of the attack. 

Sensory phenomena are conspicuous by their absence. 

Pupil Changes .—In the recoverable cases the pupils remained 
equal; they reacted to light, and accommodation was normal. 
Pupil inequality with irregularity or absence of reflex contrac¬ 
tion I found an invariable sign of a localising condition or of 
progressive degeneration. 

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310 DEGENERATIVE SYPHILITIC INSANITY, [April, 

Differential Diagnosis .—There are three conditions which 
may be confused : 1st General paralysis. 2nd. Simple acute 
alcoholic mania. 3rd. Syphilitic degeneration. 

The differentiation from general paralysis is in most cases 
impossible for a considerable time. A study of the course of 
the case with the signs and symptoms I have stated and the 
result of antisyphilitic treatment will generally within six 
months make a diagnosis possible. 

The points I have been led to consider important are—1st 
The acuteness of the attack. 2nd. The degree of mental 
enfeeblement. 3rd. The variability of the mental condition. 
4th. The character of the motor phenomena, with the absence 
of sensory phenomena and pupil changes, 5 th. The deciding 
test of vigorous antisyphilitic treatment. 

The presence of congestive attacks is not diagnostic of 
general paralysis. I have studied the records of two cases in 
this institution who had frequent congestive attacks for the 
first four months of their illness, and yet who recovered with 
antisyphilitic treatment. 

In acute alcoholic mania you get marked hallucinations of 
hearing and sight, and the diagnosis becomes clear in a month’s 
time. 

Prognosis is very doubtful; these cases are always grave. It 
depends upon the developments in the course of the case and 
the result of antisyphilitic treatment. 

Treatment. —Of the various antisyphilitic remedies potassium 
iodide is the most useful, and is followed by the most successful 
results. 

I begin with a dose of fifteen grains three times a day, 
increasing or diminishing according to the requirements of the 
case. This treatment is apt to lower the bodily weight, and it 
is probably best to substitute tonic treatment every third week. 

The bodily weight should always be maintained by nutrient 
diet, cod-liver oil, malt extract, &c. I find that the cases that 
lose weight in spite of nutrient diet, &c., invariably progress 
into paralytic degeneration. 

CASE i. A Typical Case of Syphilitic Insanity , simulating 
General Paralysis , ending in Recovery .—A. B—, aet. 36, ad¬ 
mitted September, 1895. 

Previous history .—An attack of syphilis many years ago. 

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311 

Disposition. —He has a frank and kindly disposition, and is 
hard-working. Neurotic temperament. 

Habits .—Loose ; he is given to sexual and alcoholic excesses. 
No hereditary predisposition. No previous attacks. 

Causation .—Predisposing—syphilis with sexual and alcoholic 
excesses ; actual exciting—mental worry. 

History of the present attack. —The attack was acute in its 
onset, and is of ten days’ duration. It first showed itself by 
exalted ideas, excitement, and noisy demonstrativeness. 

Physical signs. —Muscular tremors with loss of the knee 
reflexes. 

State on admission. —He has various exalted ideas, e.g. he 
says that he owns hundreds of horses, that all the charitable 
institutions in Dublin are run by him, and that the Queen is 
under his power. He is in a state of mental excitement; his 
memory is good, but his utterance is aphasic, and he is occasion¬ 
ally incoherent. He can answer most questions put to him, 
and shows a marked degree of mental enfeeblement. In 
appearance he is tall and thin ; pupils are equal, and react 
normally to light and accommodation. Muscularity is fair, 
but there is loss of fat over the body. Nervous system motor. 
Muscular tremors of the face and skeletal muscles. Knee 
reflexes are absent. There are no sensory phenomena. Circu¬ 
latory and respiratory systems healthy. Appetite is good, 
tongue clean and moist, bowels regular. Urine acid, sp. gr. 
1024. No abnormal constituents. Height 5 ft. 10 in. Weight 
10 st. Bodily health as a whole is reduced. 

Notes on the Progress and Course of the Case. —September 
14th, 1895.—Patient slept well last night, and is less excited. 
The excess of motor energy shows itself by his degree of 
talkativeness, the tremor is less marked, and he can articulate 
many test words with perfect utterance. 

15 th.—He was noisy last night, and did not sleep so well. 
This morning he is talkative, exalted, and excited, says he 
owns one million pounds sterling, keeps a harem, and is all- 
powerful. During the day he got very depressed, and prayed 
that God would have mercy on him. 

16th.—He spent the night singing and shouting, and is still 
excited and has periods of depression. 

19th.—His ideas are still exalted and his conversation erotic, 
but he is quieter and less demonstrative. He is being treated 

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312 DEGENERATIVE SYPHILITIC INSANITY, [April, 

by tonics and nutrient diet with open-air exercise. He is 
quieter and sleeps better at night His habits are very dirty. 

24th.—He still has many delusions of grandeur, is inco¬ 
herent, and has confusion of ideas. He is quieter and sleeps 
well at nights. Has become more cleanly in his habits. 

October 24th.—He is improving slowly, is quiet and less 
excitable. In his general conversation he is incoherent, but 
when drawn up sharply he can pull himself together and talk 
coherently. His power of attention and of fixing his ideas is 
very limited, however, and after talking coherently for a short 
time he becomes confused in his ideas, and is again incoherent. 
He has passing attacks of depression. 

November 10th.—He is becoming more rational in his con¬ 
versation and actions, but still has occasional relapses in which 
he talks in a grandiose manner. His mental state varies 
greatly, and he has frequent attacks of depression. The motor 
signs have been slowly improving, and are now only present in 
a slight degree. 

26th.—Since last note the motor signs have completely dis¬ 
appeared, his grandiose ideas are less marked, and the delusional 
tendency is slowly passing off. From this time onward he 
slowly improved and recovered from his delusions, day by day 
becoming clearer in his mental processes. 

In July, 1897, he was visited by his friends, who saw so 
much improvement that they insisted on taking him away, 
although Dr. Rutherford warned them that he would most 
probably break down. 

When he left there was a trace of mental weakness and an 
excitable tendency : his bodily health has greatly improved ; 
weight is 12 st. 2 lbs. 

He remained in an unstable state for two weeks, then 
relapsed and had to be readmitted. 

State on readmission .—He is mentally exalted, has many 
grandiose ideas, is excited, restless, confused in his ideas, and 
incoherent. His memory is now affected, and he can only 
answer a question imperfectly. In appearance he is healthy- 
looking and well nourished. Pupils are equal ; they react to 
light, and accommodation is normal. 

Nervous system .—Motor co-ordination is affected ; he is 
ataxic in his gait, and cannot co-ordinate to write. The struc¬ 
tures concerned with articulation are implicated ; his speech is 

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189 9-] 


BY G. A. WELSH, M.D. 


313 


indistinct and slurring. No sensory phenomena. Knee reflexes 
are absent. 

August 12th, 1896.—He is restless and excited, sleepless at 
nights, and inclined to injure his hands by beating them against 
the walls of his room. 

15 th.—He continues in the above condition. Treatment, 
nutrient diet and potassium iodide, grs. xv, t i. d., with carriage 
exercise. 

September 1st.—He is quieter, less excitable and incoherent. 
There is marked mental weakness ; he is very childish in his 
talk and actions. Motor signs are unchanged. He has a good 
appetite, and is beginning to sleep well at nights. Syr. Eastonii 
3ss, t. i. d., substituted for potassium iodide. 

30th.—Patient is improving, he has more initiative, talks 
rationally, and takes a greater interest in his personal appear¬ 
ance. His speech has improved, and only shows a slight defect 
in articulation ; the other motor signs are stationary. Iodide 
continued again. 

October 12 th.—He can now write fairly well, and is 
slowly improving. 

From this time he improved more rapidly, the mental 
weakness and delusional tendency passed off, he became 
coherent, and his memory improved. His motor signs passed 
away ; the power of co-ordination for speech, walking, and 
writing returned. In four months he could co-ordinate to walk 
and write perfectly. Speech was a month longer in improving. 

April 13th, 1897.—His friends to-day removed him on pro¬ 
bation. He is greatly improved mentally, but is still unstable 
and excitable ; when excited he is aphasic. 

October 16th.—To-day certified as being sane. There are 
no motor phenomena. 

Subsequent history .—In the beginning of 1898 he resumed 
his professional duties, and has shown no return of the disease. 

Case 2. Syphilitic Insanity with Vascular Change and 
Localising Signs , ending in Progressive Dementia. —A. C— , aet. 
50. Admitted October 24th, 1896. 

History .—Patient has a distinct history of syphilis, confirmed 
by his family doctor. The facts point during the whole course 
of the case to vascular degeneration. At the age of twenty- 
three he had an attack of paresis (with the symptoms of throm- 

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314 DEGENERATIVE SYPHILITIC INSANITY, [April, 

bosis) of the right side. He was recommended a sea voyage, and 
the paresis gradually, after twelve months’ interval, passed off. 
From that period until the present attack of mania he has 
been what his friends termed eccentric. He was restless, could 
not settle, spent his time taking long walks (on an average 
thirty miles a day), playing billiards, cards, &c., and was in¬ 
temperate in his habits. 

History of the present attack .—It is of eight days’duration, 
and first showed itself by delusions and impulsiveness. He 
imagined that his food was poisoned, and stated that when the 
impulse came on he would have killed his mother, brother, or 
sister as opportunity offered. He was excitable, restless, inco¬ 
herent, and stated that he had been insane for many years, but 
was now of sound mind. Disposition : he is of the nervous 
diathesis, of loose habits, and intemperate. Causation: pre¬ 
disposing—syphilis and vascular degeneration; exciting— 
alcohol. No previous attacks and no hereditary predis¬ 
position. 

State on admission .—Patient has marked mental weakness, 
so much so that it masks and modifies greatly his exaltation 
and excitement. His memory is defective, but he can answer 
simple questions coherently. He is a stout, well-built man, with 
an enfeebled and stupid expression ; his muscularity is good, 
there is an excessive deposit of fat in the subcutaneous tissues. 
Pupils are equal; they react to light, and accommodation is 
normal. Nervous system : the motor signs are limited to 
slight unsteadiness in gait and diminution in the knee reflexes. 
No sensory phenomena. Special senses: speech is slurring 
and indistinct; he is so weak mentally that the usual test words 
cannot be tried. Heart and lungs healthy. Appetite good. 
Tongue brown and furred. Bowels constipated. Urine acid, 
sp. gr. 1028. No albumen or sugar. Height 5 ft. 7 in. 
Weight 12 st. 11 lbs. Temperature normal, 98*4°. 

November 1st, 1896.—Continues in the condition described 
on admission. He is noisy, restless, incoherent, stupid, and 
greatly weakened in mind ; his memory is defective, he has no 
idea when or how he came here, is untidy and dirty in his 
habits. 

December 1st—-Enfeeblement progresses, he is more con¬ 
fused and stupid, speech is very indistinct He sleeps badly, 
and is noisy and restless. From this time till the end of 

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315 

March, 1897, he became more demented ; on December 22nd 
he developed a haematoma auris on the left side with more 
than a usual quantity of effusion ; on the right side there was 
chronic thickening of the aural cartilage. 

Towards the end of December the left pupil became widely 
dilated, and left-sided ptosis developed. He was so restless 
on many occasions that sulphonal in ten-grain doses was 
administered ; this drug, given at intervals, was stopped at the 
end of February. 

He continued restless and noisy for six weeks, and then came 
a remission in which he brightened up. Treatment by anti¬ 
syphilitic remedies was of no avail. 

April 9th, 1897.—To-day for the first time since admission 
he began to talk, his expression became brighter, he showed 
more co-ordination in his actions, but still remained restless. 
His weight has fallen to 1 5 2 pounds. 

12th.—Close examination for the last three days shows that 
his vocabulary is very limited, he has a tendency to repeat day 
by day what he says. He was so sensible that I was able to test 
his speech and writing. His writing shows no defective formation 
of letters, and he spells correctly what is asked of him. As 
regards his speech there is no defective articulation or syllable 
stumbling when he echoes, but when he tries to produce speech 
there is distinct slurring. 

June 12th.—Progresses towards complete mental enfeeble- 
ment; his speech has become more distinct, but his vocabulary 
is very limited ; he can whistle a tune or sing a song accurately. 
He is still restless and excitable, and requires an occasional 
dose of sulphonal. 

There is nothing of note in his case till September, when a 
paroxysmal cough developed, and on examination of his 
chest, early phthisis at the left apex was discovered. The 
dilatation of the left pupil and the ptosis are stationary. 
Weight 153 lbs. 

Under tonic and nutrient treatment his physical health im¬ 
proved, cough disappeared, and no fresh symptoms obtruded 
themselves till December, when he developed a haematocele of 
the right testicle. On careful examination the conclusion that 
it was idiopathic, and not due to injury received, seemed 
the most probable diagnosis. No history of injury or shock, 
the usual concomitant of testicular injury, could be found; the 

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316 degenerative SYPHILITIC INSANITY, [April, 

effusion was large in amount, and probably came from some 
ruptured vessel. 

1898.—Under treatment by rest, support, and inunction of 
mercurial ointment the effusion became absorbed in three weeks, 
and an examination then showed that the body and epididymis 
were enlarged and indurated ; the cord also was enlarged. In 
another month this disappeared, and he improved mentally 
and became brighter and quieter. 

An examination of his urine from time to time showed that 
he had glycosuria, alternating with bile in the urine; the urine 
was not excessive in amount, and there was no albumen. In 
February his enfeeblement had passed into quiet dementia, and 
there was no change or fresh addition to the motor symptoms. 

April 10th.—Continues as above, no change to be noted. 

General considerations .—First, in the history the confirmed 
presence of syphilis with the attack of left-sided hemiparesis. 
Recovery from the motor symptoms with continuance and pro¬ 
gression of the mental weakness. Second, an acute attack of 
mania with impulsiveness occurring twenty-five years after, with 
mental enfeeblement to such a degree as to mask the other 
evidences of his mania. Third, the progress and events in the 
case pointing to vascular degeneration. Fourth, the presence 
of speech symptoms. Fifth, a distinct remission, in which the 
speech symptoms improved and finally disappeared. Sixth, 
the occurrence of left-sided ptosis, and dilated pupil on that 
side. Seventh, failure of treatment by antisyphilitic remedies. 
Eighth, the stationary condition of the motor symptoms. 


Case 3. A Case of Syphilitic Insanity , Progressive in 
Character , showing a Remission. —A. D—, aet. 31. 

Previous history .—There is a distinct history of syphilis, 
with the prominent symptom of severe headaches, which were 
so violent that they incapacitated him from work. 

Disposition .—He was naturally clever, and had worked very 
hard. He was self-reliant, had a sanguine and happy tempera¬ 
ment. 

Habits. —Loose; no trace of an alcoholic tendency. No 
previous attacks, and no hereditary predisposition. 

Causation. —Predisposing—syphilis ; exciting—hard and 
anxious professional work. 


Primary symptoms .— Mental: the first mental symptoms 

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BY G. A. WELSH, M.D. 


317 


were change of manner and irritability, following this an attack 
of mania with grandiose ideas. During this attack he went 
about ordering large quantities of silly and useless things. The 
orders he gave were excessive and far beyond his means. To 
what extent he went may be gauged by a remark of his 
mother, when he was about to be discharged recovered. “ Do 
you think,” said she, “ that people will ever have confidence in 
him again, and employ him in professional work ? he did such 
silly and extraordinary things when he took ill.” 

Physical: then there were observed some of the physical 
signs of locomotor ataxia; for example, the peculiar way 
in which he walked. He was sent away for a month’s 
yachting, but no signs of improvement were seen, rather 
the contrary ; he became restless, developed fresh delusions 
of grandeur, wrote continuously under the impression that 
he was a great author, and was sure of a fortune by his 
writings. He sent the writings of that month to his friends 
to be published, and developed the delusion that he was fabu¬ 
lously wealthy in consequence. This was thoroughly worthy 
of a general paralytic, because he stated that although he knew 
they could not yet be published, still he had received untold 
wealth for them. Other ideas followed, he gave away what he 
called cheques for hundreds of thousands of pounds to all his 
relations and to various charities, and said he was soon to be 
made Lord Chancellor of Ireland. 

State on admission .—He has an extremely self-confident 
manner and bearing ; has delusions of grandeur. With this 
exaltation there is marked mental weakness. When his ideas 
were questioned, his emotions overcame him, and facileness 
took the place of confidence, he smiled placidly and sillily as 
he declared that these things could not be otherwise. 

Memory is good. He is coherent, and can answer questions 
sensibly and accurately. The delusions described before still 
exist strongly. 

In appearance he is a thin, spare man, with a pale skin, blue 
eyes, and a fair complexion. His pupils are irregular, the 
left being the larger. Reaction to light and accommodation 
are lost. Nervous system, motor: there is loss of motor 
power in the lower and upper extremities. He has an ataxic 
gait such as occurs in locomotor ataxia. The Romberg sign 
is present, and he cannot co-ordinate to walk along a straight 

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318 DEGENERATIVE SYPHILITIC INSANITY, [April, 

line. Co-ordination is impaired in the upper extremities, 
Sensory : sensation to touch and common sensibility are blunted 
in a marked degree. Reflexes * knee reflexes are absent; the 
plantar reflexes are normal; the cremasteric reflex is lost on the 
left side; the abdominal reflex on the left side is diminished. 
Special senses : speech is not affected ; hearing, taste, and 
smell are normal ; vision is not affected. Respiratory system : 
healthy. Circulatory system: pulse rate 108 per minute; 
regular in force and time, tension low, vessel walls healthy ; 
heart sounds are weak, but there are no murmurs. Alimentary 
system : appetite good ; tongue is coated and moist; there is 
diarrhoea from a paretic condition of his sphincter muscles. 
Urine acid; specific gravity 1030; no abnormal constituents. 
Temperature 98*4°. Height 5 ft. 10 in. Weight 9 st 3 lbs. 
On the whole his bodily condition is not good. 

September 19th, 1897.—Patient talks in an off-hand way 
about his delusions, as if they were more apparent than real; he 
emphasises strongly the point that it is only in the last month 
that he has become rich, before that time he had only what he 
made at the bar. He has a good appetite, sleeps well, exhibits 
no restlessness, and talks sensibly on general subjects. He 
suffers from incontinence of faeces, and says he has lost control 
over his bowels. This last is not an uncommon symptom in 
syphilitic insanity. 

Treatment .—Potass, iodid. grs. xv, Spt. Ammonia njxv, Inf. 
Gent. Co. ad 3 SS - Sig. Ex. aq ter in die. Malt extract 3ij 
after meals. His weight being registered every three days. 

21 st.—Remains quiet ; sleeps well at night. 

22 nd.—He was given paper and writing materials to-day. 
His writing showed his grandiose ideas, but there was no 
defective formation and no repetition of letters, and everything 
was correctly written. He still continues to work at the manu¬ 
script of his book. 

24th.—His mental condition continues as indicated above. 
He has gained two pounds in weight, and regained power over 
his rectum. 

28th.—During the morning visit patient inquired about 
the amount of money of which he said he was possessed, and 
when told, exclaimed “ I must have been off my head when 
I came here, because I have only what I make at the bar.” 
This looked hopeful, and showed his delusional tendency was 

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BY G. A. WELSH, M.D. 


319 


passing off, but he still maintained that he had written books, 
and that last week among the papers he sent off to the press 
for publication was the manuscript of a book. Beyond this 
tendency of his delusional condition to pass off his mental sym¬ 
ptoms are unchanged. He has gained three pounds since the 
24th, making in all fifty-one pounds since admission. 

October 1st, 1897.—On examination of his physical signs 
marked improvement is shown. He co-ordinates much better, 
and with greater ease when walking, the locomotor ataxic gait 
being less marked ; he can now turn quickly without losing his 
balance. His mental symptoms show he is still delusional; this 
morning he sent off a bundle of papers through the attendant 
to the publisher, these being, he said, the last of the manuscript 
of a book he had written. 4 The dose of iodide has been increased 
to 20 grains. 

8th.—During the last week his mental enfeeblement shows 
signs of passing off; he has more initiative, and attends to his 
dress and personal appearance in a more marked manner (on 
admission he was careless and untidy in his personal habits). 
The physical signs are in the condition indicated by the note 
of October 1st, 1897, with this exception, that his pupils now 
react to accommodation, though not to light. Tonics substi¬ 
tuted for Pot. Iodid. Weight 135 lbs. 

18th.—There is still further improvement in his mental con¬ 
dition, his delusion about being an author is not so strong ; he 
never refers to it and has ceased writing. 

20th.—Treatment by Pot. Iodid. begun again. 

November 4th, 1897.—Mental improvement is still more 
marked. All medicinal treatment (for the time being) has 
been stopped. He puts on weight to the extent of 1 lb. per 
week. 

12th.—Patient has now recovered from the more acute 
mental symptoms. His delusions have disappeared, he recog¬ 
nises that they were delusions ; the memory of his illness being 
very perfect, he is able to tell all that he thought and did. He 
writes sensible and coherent letters to his friends, and talks and 
acts in a rational manner. There is no further improvement in 
his locomotor ataxia. Weight 141 lbs. 

December 2nd.—Improvement still continues, there is only a 
faint trace of enfeeblement. He has become a sane individual, 
takes the initiative in conversation, and expresses opinions of 

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320 DEGENERATIVE SYPHILITIC INSANITY. [April, 

his own. He is calm and composed, mixes with the other 
convalescent patients, plays billiards, and altogether he has 
recovered his place as a sane social unit. Tonic treatment is 
being pursued, and his bodily health is improving. Weight 
143 lbs. 

12 th.—To-day he was examined with the following result. 
His mental system is in good tone, its processes are clear and 
healthy, he is decisive in his ideas and judgments ; all delu¬ 
sional tendency has disappeared, his memory is not defective, 
and he is capable of doing mental work. His locomotor ataxy 
is stationary, but his co-ordination has improved, and although 
ataxic in his gait his movements are interfered with little; his 
pupils are unequal, and still fail to react to light, reacting to 
accommodation. 

18th.—Discharged recovered, with the following medicinal 
directions, that as a gouty person takes prophylactic treatment, 
so should he take Pot. Iodid. The ordinary precautions as to 
regime and overwork were given. 

Readmitted in June, 1898, suffering from a similar attack. 
In this recurrence he is gradually passing into progressive 
degeneration ; the mental and motor phenomena, in spite of 
antisyphilitic treatment, are slowly progressing. 


Discussion 

At the Annual Meeting at Edinburgh, 1898. 

Dr. Clouston said that syphilitic insanity had advanced to a more important 
stage than when he first knew about it. Dr. Hughlings Jackson had laid it down 
that the syphilitic poison never affected the nervous substance directly, but only 
through the blood-vessels and the neuroglia. They had passed beyond the dictum 
of so great an authority as Dr. Jackson, and it was a very important point. There 
was no doubt, from what Dr. Welsh and others had shown, that the toxine of 
syphilis actually and directly attacked the nerve-cell and fibre, and did not affect 
those organs merely through the secondary effect on the vessels and neuroglia. 
The question whether there was not a syphilitic insanity that was directly dynamical, 
but where they had no motor symptoms, admitted of discussion. It had been said, 
and he thought that his experience confirmed it, that there was such a kind of case, 
commonly of a young man who had syphilis, and who in a year or two began in the 
first place to fall off in health, he became anaemic, bad-coloured, and mentally 
depressed, moody, and in a short time full of suspicions,—the kind of a case 
which was described in the Crichton Institution by Dr. Stewart. As a general rule 
there was an hereditary tendency to insanity. He would urge on them to use anti¬ 
syphilitic treatment and fresh air and exercise. Some cases in his experience had 
become vascular syphilis with localised paralysis. A few had resulted in real dege¬ 
neration of tissues of the brain. He did not know if all the cases that were 
curable were dynamical. You could say that because they were curable they were 
dynamical. He believed there were actual demonstrable changes in the nerve cells 
and fibres that were curable under treatment or by natural means. He asked if they 
could state any pathological features which served as tests between the general 
paralysis and syphilis. For himself, he doubted whether this could be done. There 

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1 899.] MUSEUM FOR PATHOLOGY AND PHYSIOLOGY. 


321 


was always an element of uncertainty in the cases of syphilis and general paralysis. 
They should be vigorously treated as syphilitic. They should have the benefit of 
the doubt. 

Dr. Ireland said that he came to the conclusion that syphilis, as a general rule, 
spared the nervous system. Were there cases in which it was proved that the 
nerve-cells were affected and the vessels were not affected or not degenerated ? He 
questioned if there were such cases. Dr. Tuczek complained that many in studying 
general paralysis forgot to study the fibres. Dr. Welsh had said very little about 
the fibres. He believed a great many cases were merely insane people who had 
contracted syphilis. 

Dr. Ford Robertson said it would be difficult to prove that they could have a 
case in which there was affection of the nerve-cells without affection of the 
vessels, because the disease in these cases often affected the very minute blood¬ 
vessels, and he did not see how they could exclude the presence of the vascular 
disease. Regarding the question of the distinction between syphilitic insanity and 
general paralysis, he really did not know any distinction between them. 

The President referred to two cases reported by him in the Journal for Janu¬ 
ary, 1887; both still remain well. Although he did not hold that all cases of 
general paralysis were syphilitic, vet they ought to bear in mind that a case might 
be syphilitic and might be curable. His ordinary treatment continued to be the 
green iodide of mercury with small doses of opium. 

Dr. Welsh, in reply to the President, said that he thought dynamical was a 
better term than functional, because it treated of the structure of the cell. Func¬ 
tional did not give any indication of structure. 


The Necessity for a Museum and Laboratory of Cerebral 
Paihology and Physiology . By A. H. Newth, M.D. 

It is probably not an exaggeration to say that no physicians 
have so many favourable opportunities for pathological obser¬ 
vations as those connected with asylums. Post-mortem exami¬ 
nations are generally expected to be made on all patients who 
die in asylums. There are in most, if not in all the asylums, 
well-appointed mortuaries for conducting these examinations, 
and every facility is available for preparing and preserving 
morbid specimens and making microscopical and other obser¬ 
vations. In some asylums special pathologists have been 
appointed. 

In spite of these advantages the study of psychological 
pathology has not advanced so much as might be expected, 
for though there are many earnest workers in pathology and 
microscopy among the superintendents and medical officers, 
their labours are to a very great extent depreciated in value 
from too much individualism, a lack of uniformity in working 
out the details, and a want of opportunity for comparison of 

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322 


MUSEUM FOR PATHOLOGY AND PHYSIOLOGY, [April, 


their work with that of others and by others. The thirty 
years that I have had the privilege of compiling the index for 
the Journal of Mental Science have afforded me abundant 
opportunities for noticing the very numerous accounts of the 
valuable specimens of brain histology and pathology both 
macroscopical and microscopical that have been recorded, and 
it is to be regretted that they have not been so preserved as to 
be made available for comparison and observation. During 
my residence in the Sussex County Asylum I prepared a large 
number of pathological specimens and mounted several thou¬ 
sand microscopical slides ; but practically they were all thrown 
away, and this, no doubt, is the experience of many. A very 
large amount of valuable pathological material is lost for want 
of the possibilities of preserving it. Asylums generally are not 
the proper places for the preservation of pathological prepara¬ 
tions. Even if they were, scattered as they are over so large 
an area, it would be extremely difficult for students and others 
to obtain access to them. 

What is required, and it is an absolute necessity, is the 
formation of a suitable museum in some accessible situation 
where pathological specimens of brain and microscopical pre¬ 
parations of healthy and diseased cerebral tissue should be 
preserved and made available for observation and comparison. 

This museum would be extremely interesting and instructive, 
and, I venture to think, unique. If arranged in a scientific 
manner it would prove of great value not only to alienist 
physicians, but also to psychologists who are engaged in the 
study of the physical basis of mental action. 

There might, for instance, be preparations showing the 
gradual development of brain from the embryo to the adult; 
of degenerative brains, as in idiots and imbeciles; criminal 
brains ; brains showing disease or injury of special parts, to 
illustrate local cerebral functions; the different forms and 
situation of tumours of the brain ; atrophied brain, &c. The 
JOURNAL frequently gives illustrations of these, but it would 
be far more important to students to be able to see the 
specimens themselves, Where the actual brains could not be 
obtained casts might be taken and sent to the museum. 
Photographic illustrations of diseased brain and of peculiar 
phases of lunacy would also find a place and be of general 


interest. 


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BY A. H. NEVVTH, M.D. 


323 


Workers with the microscope would send their preparations 
which might be arranged systematically so as to be easily 
referred to and compared with those of others. These micro- 
scopists would have an impetus to work more energetically 
when they felt that their labours were not in vain, but that they 
would be honoured by being placed where those able to 
appreciate and profit by them might have opportunities for 
observing the results of their work and deducing facts from 
them of scientific value. 

If the various labours of these microscopists could be so 
organised that each might prepare some special part of the 
brain, in time a most complete series of microscopical speci¬ 
mens might be obtained to demonstrate the histology of the 
brain. This collection, carefully arranged, would be of untold 
value to the science of psychology. 

Much has already been done, and is being done, by many 
earnest workers in the microscopical pathology of the brain, 
but the task of forming a complete or even an approximately 
complete series of preparations to demonstrate cerebral pathology 
is so enormous that no single person, however hard he laboured 
at the subject, could accomplish more than the most insigni¬ 
ficant quota to the whole. It is only by concentrated, con¬ 
nected, uniform, combined efforts that any satisfactory results 
can be achieved. 

With united efforts under a competent supervisor or director, 
who would apportion the various spheres of labour, compare 
the results and record them, and also arrange and tabulate the 
various specimens, making them easy of access, so that others 
may be able to work out facts from them, the study of the 
physiology and pathology of the brain would in time be so 
advanced that very definite and satisfactory conclusions could 
be obtained from them. 

The pathology of insanity being thus made more perfect, it 
would be possible to get a more correct nosology, a more satis¬ 
factory diagnosis and prognosis, and consequently a more 
decided method of treatment. In fact, tend to make the study 
of insanity an exact science. 

This is no Utopian idea; it is and has been the result of 
painstaking pathological investigations in all other forms of 
disease. With the splendid organisation that the various 
asylums furnish, under the able assistance of the medical 

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324 


MUSEUM OF PATHOLOGY AND PHYSIOLOGY, [April, 


officers, such a work might be accomplished in Great Britain 
which the world would be proud to recognise. 

The organ of the Association is termed the Journal of Mental 
Science; in order to render it more worthy of this title the 
Association must consider seriously and determinately the 
necessity of founding such a museum. 

In connection with the museum there would have to be a 
laboratory ; this ought, as a natural consequence, to be under 
the control and direction of a committee of the Association. 
The London County Council has already fitted up one at Clay- 
bury Asylum, with Dr. Mott as pathologist. The Lancashire 
asylums have appointed several pathologists at an expense 
of £900 a year. The West Riding of Yorkshire has for many 
years been distinguished for its special pathological work under 
Dr. Bevan Lewis, whose researches in neuro-pathology are a 
matter of history. The State of New York has provided a 
laboratory for the correlation of scientific investigation in psy¬ 
chiatric and neurological research, which is ably described by 
Dr. Gieson in the October number of the Journal. Most of 
the Scottish asylums have joined to form a laboratory under 
the able superintendence of Dr. W. Ford Robertson. The Com¬ 
missioners have repeatedly insisted on the importance of patho¬ 
logical investigations in insanity. Surely it is time for the 
Association to bestir itself and establish a laboratory in London. 
The great difficulty, of course, is the expense of such an under¬ 
taking, but this can easily be met. It only needs a recommen¬ 
dation from the superintendents to the committees of the 
various asylums pointing out the urgent need of such an under¬ 
taking in the interest and importance of pathological investiga¬ 
tions to obtain a contribution from each towards this work. I 
think also it would not be unreasonable to expect, if the matter 
were properly laid before the Government, and it were clearly 
shown how important for the welfare of society generally the 
scientific investigation of the nature of insanity would be, that 
the State would readily grant a yearly sum for this purpose, and 
the Commissioners may be induced to support this application. 
The College of Physicians or Surgeons in London will also, 
no doubt, act as liberally towards the scheme at least as the 
College of Physicians in Edinburgh has done. For the study of 
insanity has not to be confined to the medical officers of asylums, 


but it is of importance to every medical man who has constantly 

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1899 ] 


BY A. H. NEWTH, M.D. 


325 


to meet it and treat it in its early and possibly remediable form. 
A more correct knowledge of the pathology of insanity will 
eventually tend to check the increase of the disease which every 
year is becoming more appalling. 

There is a valuable library connected with the Association ; 
this ought to be available for loan not only to the members 
but to the profession generally, and should be under the care 
of a librarian who might also be curator of the museum and 
pathologist to the laboratory. It would also possibly be an 
advantage if he were sub-editor of the JOURNAL as well, acting 
under the direction of the several present very efficient editors. 
His assistance to them would no doubt be valuable, as having 
constant access to the library he would be able to refer to what 
has been written on the different subjects treated of, and make 
comparisons as to the various opinions that are or have been 
held on them. In fact, he would be in a position to write a 
sort of leading article in each number of the JOURNAL. 

There are many capable men who would willingly act as 
curator and librarian for a mere honorarium. It is a question 
whether it would be desirable that he should be one devoted to 
original research, as this would interfere with the important 
duty that he ought to perform of collaborating, classifying, and 
directing the work of others. 

If the West Riding alone has done so much ; if the Lanca¬ 
shire asylums, and some of the Scottish asylums are able to 
combine to form the splendid laboratory that is doing such 
excellent work already ; if the London County Council has 
established a laboratory ; if the New York asylums are to the 
fore in this respect, surely it is time that the Association should 
prove by decided effort that it is not behindhand in the 
endeavour to make the science of the pathology of the brain as 
advanced as that of most other diseases. The value of the 
laboratories for cerebral research is already beginning to be 
proved, the investigations of Dr. Mott have received recognition 
by Drs. Bevan Lewis and Oppenheim, and Dr. Ford Robertson is 
engaged in a work on cerebral pathology. If the result of the 
few laboratories that are already formed is so satisfactory, what 
may not be expected from a more thorough and extensive 
combination of all or nearly all of the asylum workers in Great 
Britain ? 


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326 


MENTAL STATE IN APHASIA, 


[April, 


Considerations on the Mental State in Aphasia . By 
Conolly Norman. 

The subject of aphasia is one which has offered some of the 
most interesting problems presented to the physician for solu¬ 
tion, and, although many remain unsolved, yet the study of 
aphasia has been more fertile of great discoveries as to the 
function than that, perhaps, of any other brain symptom or 
group of symptoms. The researches of Broca, indeed, were the 
beginning of localisation, and, as far as the cerebral cortex is 
concerned, formed the starting-point of any scientific knowledge 
which has since been attained. 

The whole field of aphasia is full of interest—of practical 
interest to the physician and the surgeon, of interest to the 
scientific thinker, and of interest to the historian of our art, who 
will some day have to record the triumphs won therein as among 
the noblest which the human intellect shall have achieved in 
the mighty struggle it ever wages with Nature to wrest from 
her one by one her most recondite secrets. 

To us who work in the comparatively limited sphere of prac¬ 
tical psychiatry, aphasia has, besides its general or scientific 
interest, a further importance as bearing upon the question of 
how far a lesion, theoretically and according to our present 
lights, limited in extent, can affect that total of the higher 
nervous functions which we assume under the name of mind. 
How far, again, is the cerebral faculty of speech necessary for 
the maintenance of thought; how far essential to the education, 
the building up, of the mind ? 

The relation of words to thought is a subject which it is hard 
to discuss without departing from the biological and assuming 
the metaphysical, or at least the teleological position. That the 
process of thinking can be carried on without words Max Muller 
denies, but Preyer seems to show that the great philosopher of 
language is too absolute in this respect. Preyer points out that 
we cannot deny thought to the infant at a time before he has 
learned to utter a single word, and comes to the conclusion that 
primitive thinking is not bound up with verbal language. Of 
course, he in no way den